Letter from ABI2024:
Dear Colleagues,
It is with great pleasure that we present the accepted scientific abstracts from the North American Brain Injury Society’s 17th Annual Conference on Brain Injury in this issue of the Journal of Head Trauma Rehabilitation. The conference was held in Las Vegas, Nevada March 27-30th, 2024.
This year we were delighted to have received over 180 abstracts from investigators, clinicians, and researchers from around the world including some of the world’s leading clinical, academic, and research institutions. Moreover, we are proud of the high quality of research submitted and the broad range of relevant, interdisciplinary topics reflecting current advances being made across the continuum of care in the field of brain injury.
For those of you who were unable to attend the NABIS 2024 meeting, we are pleased to present accepted scientific abstracts in the Journal of Head Trauma Rehabilitation (JHTR). In addition to the scientific oral and poster abstracts, NABIS- ABI 2024 had over 50 invited speakers presenting on the latest advances in ABI neuroscience and rehabilitation research. With the theme of “Evidence Informed Best Practices and Guidelines in Brain Injury Medicine and Neurorehabilitation”, the conference planning committee developed a dynamic educational program aimed at achieving optimal outcomes through interdisciplinary collaborations. Clinicians, researchers, administrators, and other brain injury professionals gathered during this four-day multi-track event which covered a variety of adult and pediatric brain injury topics including medical best practices, rehabilitation, research, community integration, life-long living, with advocacy and a knowledge translation emphasis. The conference program is posted on the NABIS website, www.abi2024.org.
This past year, NABIS was also pleased to showcase six inspirational Pre-conference Courses. Pre-eminent leaders presented on Evidence Informed Management of Mild TBI’s, Assessment Tools for the Assessment and Management of Disorders of Consciousness: Novel Approaches for Motor Rehabilitation following ABI, and Pediatric Brain Injury: Best Practices to Enhance Clinical Care and Optimizing Outcomes. Finally, Brain Injury as a Chronic Health Condition and Training Emotional Recognition in Self and Others following ABI as half-day courses segued to the main conference. The main conference also featured leading experts presenting on essential ABI topics for every practicing clinician as well as researchers. Interactive sessions on Mild TBI, Disorders of Consciousness, Neuroplasticity, and Recovery Best Practices Rehabilitation were components of the broad-based program. Examples of practical education included but were not limited to headache evaluation management, pharmacologic rehabilitation, vision and vestibular current practices, neurologic music therapy and a context for applied complementary/alternative and integrative therapeutics. The educational offerings were rounded out with updated approaches to maximize community integration, lifelong living, and how best to manage ABI as a chronic condition to maximize one’s quality of life.
Thank you for all your contributions toward making ABI 2024 a most successful educational, informational and networking event. We look forward to seeing you at future NABIS/IBIA/IPBIS meetings. We also thank you for your support of this multi-disciplinary dynamic organization and are hopeful for new membership growth in the upcoming year. We welcome your feedback on how this society can improve and meeting your society membership needs. Whether it is in research or clinical care, NABIS and IBIA stand behind the premise that advances in scientific research and translational clinical care will ultimately provide the best outcomes for those individuals and families affected by brain injuries as well as the community.
Sincerely,
Alan H. Weintraub, MD, FACRM, FAAPMR
ABI 2024 Conference Chair
Chair North American Brain Injury Society
10 Traumatic Brain Injury Induced Vision Impairment and Histone Methylation
Rajaneesh Gupta1
1Banaras Hindu University, Varanasi, India
Traumatic brain injury (TBI) is a major cause of mortality and morbidity in the world. TBI induces a chronic disease process causing visual loss which in turn affects day to day life of patients as well as their families. Understanding the underlying molecular mechanisms of TBI-induced vision impairment is a great challenge for neurobiologists, ophthalmologists, and other clinical practitioners. Our animal research study shows that TBI causes damage to the optic nerve and thinning of the retina culminating in compromised vision processing and perception. Axonal degeneration and demyelination in optic nerve and retinal ganglion cells (RGCs) loss in the retina is a crucial feature of vision impairment triggered by TBI. We have found that histone 3 dimethylation at lysine 9 residues (H3K9Me2) on antioxidants gene promoters like SOD can trigger oxidative stress in RGCs and oligodendrocyte precursor cells (OPCs) that was strongly correlated with retinal thinning, impairment of the retrograde transport of axons from visual cortex to neural retina, and demyelination of optic nerve following TBI. Our study suggests that epigenetic regulation of genes associated with oxidative stress could be a potential therapeutic target to restore visual deficits after TBI.
12 Strain-Rate Dependent Nature of Human Brain Tissue Under Shock Loading
Mariusz Ziejewski1; Mohammed Hosseini Farid1; Mehran Fereydoonpour1; Ghodrat Karami1
1North Dakota State University, Fargo, United States
In the realm of biomechanical analysis of brain tissue, the precise understanding of the material properties of intracranial head organs holds utmost significance in the exploration of head injury biomechanics. Research has revealed the substantial rate-dependent nature of these biological tissues, thereby emphasizing the necessity to ascertain their material properties within the spectrum of deformation rates they encounter.
This paper employs a meticulously validated finite element model of the human head to delve into the biomechanics associated with impacts and blasts, both of which can result in traumatic brain injuries (TBIs). Our investigation encompasses simulations involving diverse impact directions and velocities. Additionally, we examine scenarios involving both helmeted and un-helmeted heads subjected to blast shock waves.
Our study illuminates that brain strain rates range from 36 to 241 s-1, which is approximately 1.9 and 0.86 times the head acceleration observed during impact and blast scenarios, respectively. The skull, on the other hand, experiences strain rates spanning from 14 to 182 s-1, translating to roughly 0.7 and 0.43 times the head acceleration associated with impact and blast situations.
Furthermore, the outcomes of our incident simulations unveil brainstem and dura mater strain rates within the ranges of 15 to 338 s-1 and 8 to 149 s-1, respectively. These findings not only contribute valuable insights into the characterization of brain tissue, cranial bone, brainstem, and dura mater, but also provide a foundational framework for the pre-selection of material properties in anticipation of computational dynamic studies concerning the human head and brain.
14 Is Virtual Service Delivery a Viable Way To Meet Clients’ Needs and Interests: A Needs Assessment of Virtual/Hybrid Day Programming for Clients With Acquired Brain Injury
Sydney Rossiter1; Brooke Davis1
1University Of Ottawa, Ottawa, Canada
Vista Centre Brain Injury Services (VCBIS) offer clients with acquired brain injury a day program of social leisure activities with the objective of connecting them with other clients and promoting skill development to encourage self-efficacy in their community. During the COVID-19 pandemic, the VCBIS day program pivoted to virtual and hybrid programming to maintain service to clients. Program staff are now considering the future of these modes of service delivery. Evaluators conducted a needs assessment for the virtual and hybrid day program to determine whether this mode of program delivery would 1) meet clients’ needs and 2) be attractive to clients in a way that promotes participation in the program. Evaluators used a mixed methods approach, including a VCBIS record review, surveys of clients (n=28), VCBIS staff (n=3) and alternative service providers (n-6), and client focus groups (n=11). Findings from the evaluation indicated that clients have a similar experience of virtual and in-person programming (i.e., similar levels of enjoyment, interest in activities, social connection, skill development), even if clients generally had a preference for one mode of service delivery over the other due to personal interests and accessibility needs. Contrasting this finding, clients generally perceived hybrid programming less favorably on most measures. Clients rated their enjoyment of hybrid activities (M=2.10, SD=.89) significantly lower than the in-person (M=4.65, SD=.67) and virtual (M=4.19, SD=.87) activities; however, there was no significant difference in enjoyment ratings for in-person and virtual participation. During focus groups, clients frequently reported that they struggled to see or hear others clearly during hybrid programming. Staff and alternative service providers echoed these sentiments in their survey responses, indicating that hybrid programming was often challenging to facilitate due to client lack of interest in the programming and technological barriers. Clients did indicate, however, that participating in hybrid programming was much preferred over missing day programming sessions or having no access to programming at all (e.g., due to weather, COVID). Based on these findings, evaluators recommend that VCBIS: 1) continue to offer a virtual day program; 2) tailor program activities to the mode of service delivery; 3) adopt a flexible approach that allows clients to join virtually in cases where a session would otherwise be missed; and 4) implement ABI appropriate ongoing client feedback measures.
15 Improvement of Functional Mobility of Functional Neurologic Disorder (FND) Patients in the Inpatient Rehabilitation Facility Measured Using Wee FIM Scores
Evelyn David1
1Children Specialized Hospital, New Brunswick, United States
Background
Functional Neurologic Disorder (FND), or conversion disorder, is a psychiatric disorder that has no organic basis with symptoms affecting sensory and motor function which are not consistent with known neurologic disorder or other medical diseases. Currently, the understanding of FND is largely limited and evolving. This retrospective study will increase the knowledge of how FND impacts the patient’s dysfunction in mobility and outcome of rehabilitation using Wee FIM scores.
Methods
There were total of 36 (26 females,10 males) patients who were admitted from 2016-2022. (n=1) in 2016, (n=4) in 2017, (n=2) in 2018, (n=4) in 2019, (n=12) in 2020, (n=9) in 2021, (n=4) in 2022. Patient admitted should have a formal diagnosis by a provider from the referring facility with caregiver’s acceptance of an FND diagnosis. Patients received Wee FIM scores on functional mobility on admission and discharge. Scores were compared from admission to discharge. Patients received therapies from a multidisciplinary team; medical, nursing, physical, occupational, child life, recreational, psychology, and psychiatry. Therapies were evaluated according to their individual needs and discussed weekly during the family meeting. Their length of stay was dependent on their daily progress and patient/family cooperation.
Results
Wee FIM admission scores; Unable to walk; 1 is total assistance TA (44%). 2 is maximum assistance Max A (22.2%). 3 is moderate assistance Mod A (0%). 4 is minimal contact Min A (8.3%), 5 is supervision S (8.3%). 6 is modified independence Mod I (13.8%) and (2.7 %) was 7 for Total independence (TI). Unable to negotiate stairs; TA (75%), Max A (2.7%), Mod A (0%), Min A (2.7%), Needs supervision (5.5%), Mod I (13.8%), TI (0%). Transfers from bed to chair/chair to bed; TA (8.3%), Max A (5.5%), Mod A (8.3%), Min A (5.5%), supervision (22.2%), Mod I (41.6%), TI (8.3%). Discharge scores; (2.7%) was unable to walk, a decrease from 44%. Max A, Mod A, Min A were (0%), supervision (5.5%), Mod I (52.7%), patients who walked and TI (38.8%) an increase from (2.7%). Negotiating stairs; TA (2.7%), Max A, Mod A, Min A were (0%), supervision (5.5%), Mod I (55.5%) up from 41.6%, and 7 (36.1%) significantly improved from (8.3%). For transfer: none needed assistance or supervision, (50%) each for Mod I, increased from 13.8% and TI definitely up from (0%). Length of stay were from 1 day to 44 days.
Conclusion
FND can be very debilitating that needs a multidisciplinary team in a rehabilitation facility to improve the patient’s functional mobility. Treatment includes management of anxiety, depression, cognitive behavior, family, physical and occupational therapies.
16 Wernicke-Korsakoff Syndrome Following Sleeve Gastrectomy
Evelyn David1, Wernicke-Korsakoff Syndrome Following Sleeve Gastrectomy Janay Parrish, Wernicke-Korsakoff Syndrome Following Sleeve Gastrectomy Lara Aunio, Wernicke-Korsakoff Syndrome Following Sleeve Gastrectomy Emily Lowry, Wernicke-Korsakoff Syndrome Following Sleeve Gastrectomy Erica Bissonnette
1Children Specialized Hospital, New Brunswick, United States
Case Diagnosis A 16-year old girl with a history of asthma, diagnosed with Wernicke-Korsakoff Syndrome following a sleeve gastrectomy.
Case Description or Program Description The patient presented to the emergency department with acute onset generalized weakness 3 months after a cosmetic sleeve gastrectomy in Mexico. She did not undergo pre-operative screening or education. Post-operatively, she reported vomiting and poor oral intake. She took Biotin, B12, and iron supplements but received no follow up. Neurologic exam revealed nystagmus, and labs showed thiamine deficiency. MRI demonstrated hyperintensities involving bilateral medial thalami, the periaqueductal grey, and bilateral mammillary bodies, consistent with Wernicke’s Encephalopathy. She completed a course of intravenous thiamine and was transferred to acute inpatient rehabilitation on oral supplementation.
Setting
Acute Inpatient Rehabilitation
Assessment/Results
The patient showed inattention, poor motivation, and short-term memory deficits during therapy. She was diagnosed with Wernicke-Korsakoff Syndrome on neuropsychological assessment. During her rehabilitation course, she made significant improvements in strength and activities of daily living. However, she had persistent cognitive deficits that limited her progress.
Discussion (relevance)
Wernicke’s encephalopathy is an uncommon complication of gastric sleeve procedures, developing within 6 months due to thiamine deficiency. Although B12 absorption in the small intestine is preserved, patients may develop thiamine deficiency through vomiting and poor oral intake. Typical symptoms include ataxia, nystagmus, and diplopia. Many patients make a full recovery following thiamine supplementation. Here, we describe a progression from Wernicke’s Encephalopathy to Wernicke Korsakoff syndrome in the setting of poor follow up. Therapy interventions were beneficial for the patient. However, she suffered long term impairment.
Conclusions
Wernicke Korsakoff Syndrome is a permanent neurological condition that can significantly impair quality of life and functional status. With new guidelines recommending bariatric surgeries at an earlier age, it is important to ensure adequate follow up and education on nutritional supplementation and to recognize the symptoms of thiamine deficiency post-operatively.
17 Immersive, Interactive Virtual Reality Scenarios for Traumatic Brain Injury Memory and Eye Recovery: A Pilot Study
Kristen Linton1; Bahareh Abbasi1; Melissa Gutierrez Jimenez1; Jaylyn Aragon1; Savanna Monson1
1California State University Channel Islands, Camarillo, United States
Background
Early rehabilitation is necessary for people with traumatic brain injuries (TBI) to recover, yet 77-88% of people with TBI ever receive rehabilitation. People with TBI who are Hispanic, those without insurance, public insurance, or transportation challenges are even less likely than others to receive rehabilitation. Due to its potential to be mobile and low cost, Virtual reality (VR) is recommended as a rehabilitation option that addresses these challenges. Immersive, interactive VR has improved outcomes for people with TBI including memory and eye tracking.
Methods
This community-based participatory research project included focus groups with people with TBI (N = 12) to design virtual reality scenarios to address common rehabilitative needs. Prospective memory and eye tracking were described as the most common challenges. The authors then developed and assessed the rehabilitative effects of two new virtual reality scenarios using a HTC Vive headset on prospective memory and eye tracking among people with brain injuries (N = 11) randomized to intervention and control groups. The intervention group (n = 6) participated in the 12-minute memory scenario twice a week for 6 weeks. The control group (n = 5) participated in a memory card game for 20 minutes twice a week for 6 weeks and then participated in the memory VR scenario twice a week for 6 weeks. Four participants received 12 sessions of the 6-minute eye tracking scenario.
Results
On an objective memory test, participants in the VR intervention group (66%) improved their memory more often than the memory card control group (0%) after about 12 sessions each. On a PMRQ memory scale, the intervention and control group did not have statistically significant different mean scores after six weeks. Three out of four (75%) of participants improved their eye tracking ability after they completed the eye tracking VR scenario.
Implications
An efficacy study of the two new VR scenarios will be conducted next. Future research should assess the appropriateness of VR for different types of brain injury and co-occurring conditions.
18 VA Tele-Traumatic Brain Injury (TBI) Program: Increasing Veterans’ Access to TBI Care
Mi-Hyon Cho1
1VA Hudson Valley Health Care System, Wappingers Falls, United States
Traumatic Brain Injuries (TBI) have been described as the “signature injury” from the Iraq and Afghanistan wars due to the high prevalence of blast exposure. In 2007, the Veterans Health Administration (VHA) implemented a national clinical guideline that required that providers screen all Veterans who served in combat operations for TBI. Then if a Veteran has a positive TBI screen, a TBI specialist should perform a comprehensive TBI evaluation (CTBIE) to determine a diagnosis and develop an individualized treatment plan. However, due to shortages in TBI specialists, some VA facilities were not able to complete CTBIEs for Veterans who screened positive.
To fill this gap, in 2016, VA Hudson Valley (HV) TBI care provider Dr. Cho reached out to a VA facility in Hawaii that needed assistance. To allow VA HV to provide virtual care for their Veterans, they developed a Telehealth Service Agreement (TSA). Using a modality called Clinical Video Telehealth (CVT), Veterans could go to the closest VA facility in Hawaii and connect virtually with a provider in HV, New York to complete a CTBIE. After providing successful gap coverage and a warm handoff to a newly hired TBI provider at the site in Hawaii, Dr. Cho used the framework to partner with other VA facilities who needed support providing TBI specialty care for their Veterans.
In 2021, VA HV was awarded funding from the VA Office of Rural Health which allowed them to form a more comprehensive Tele TBI Program - consisting of three TBI providers, two speech therapists, one psychologist and a TBI coordinator. To reduce patient drive times, reduce COVID-19 exposure, and improve access to care, the team also rolled out a new virtual care modality that allowed Veterans to connect with providers in HV from their personal devices.
To date, the program has provided TBI virtual care consults to over 1,400 Veterans at 20 VA facilities across the US and is working on expanding care to Active Duty Service Members (ADSM) at a Department of Defense site.
Since November 2022, 12% of HV Tele-TBI patients (169) were surveyed using a ten-question patient satisfaction survey. On average, patient satisfaction total scores were 4.7 out of 5.0. Of the 169 patients surveyed, 98% reported that they “felt comfortable discussing medical issues with their provider during the Telehealth visit,” 95% “would recommend tele-health to others,” and 98% said “overall, they were satisfied with the telehealth visit.”
22 Symptoms and Biological Markers in Traumatic Brain Injury Patients 3-12-Months Post-Injury
Kathryn Gerber1; Gemayaret Alvarez1; Victoria Behar-Zusman1; Arsham Alamian1; Charles Downs1
1University Of Miami School Of Nursing And Health Studies, Miami, United States
Background
Neuroinflammation is an important feature of traumatic brain injury (TBI). However, the biological markers of TBI and their connections with cognitive, affective, and physical symptoms remain poorly understood, particularly in the 3-12-month time-period post-injury. Thus, the objective of our study was to examine the relationships between symptoms, biomarkers of neuroinflammation, and functional outcomes in TBI patients 3-12 months post-injury.
Methods
A cross-sectional study of 39 TBI patients was performed at a South Florida TBI clinic between May 2022 and June 2023. All patients were between 3-12 months post-injury during study participation. Clinical data, including initial Glasgow Coma Scale (GCS) score, pharmacological information, and patient co-morbidities, was obtained from the Electronic Health Record. Participants also completed a Sorting-Working Memory Test, Neuro-QOL Cognitive Function, Anxiety, Depression, and Sleep Disturbance inventories, a modified symptom checklist from the Brain Injury Association of Virginia, and the Disability Rating Scale (DRS) and Satisfaction with Life Scale (SWLS) as measures of physical function and quality of life, respectively. Multiple plasma biomarkers were assayed. The sample was characterized and associations between symptoms, biomarkers, and functional outcomes were examined using linear regression. Group means were calculated for outcomes and biological data, and analysis of variance (ANOVA) was used to compare between-group means.
Results
The sample consisted of 69.23% male participants, with the most common cause of TBI being motor vehicle accident (71.79%). The top 5 symptoms reported by participants included (1) memory problems, (2) difficulty concentrating, (3) easily agitated, (4) trouble focusing with background noise, and (5) having to check and recheck. Of the top 25 symptoms reported by TBI patients, nearly half (12 out of 25) were cognitive symptoms. Changes in concentrations of the biomarkers over time was assessed, and BDNF levels were found to increase (4191.38 ±275.87 pg/ml 3-6 months post-TBI, 5121.33 ±251.70 pg/ml 6-9 months post-TBI, and 5872.92 ±195.54 pg/ml 9-12 months post-TBI, p = .045), while injury severity was not associated with difference in mean concentrations. GCS category and Satisfaction with Life (SWLS) were also significant [F(1, 34) = 5.17, p = .029]. BDNF was inversely associated with cognitive battery outcomes and positively associated with time since injury. S-100β was positively associated with anxiety score, depression score and hospital length of stay; GFAP was also positively associated with anxiety score and hospital length of stay. IL-6 was inversely associated with time since injury and cognitive function.
Conclusions
Several biological markers were associated with functional outcomes during the 3-12-month post-injury period. We found S-100β, GFAP, IL-6 and BDNF to play a larger role in the TBI recovery period than other biomarkers examined. Additionally, focus on cognitive symptoms should be clinically integrated into patient care to improve TBI patient outcomes.
23 Summary of the Centers for Disease Control and Prevention’s Self-reported Traumatic Brain Injury Survey Efforts
Jill Daugherty1; Alexis Peterson1; Lindsey Black2; Dana Waltzman1
1Centers for Disease Control and Prevention, Atlanta, United States; 2Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Division of Health Interview Statistics, Atlanta, United States
Introduction
Caused by a bump, blow, or jolt to the head, a traumatic brain injury (TBI) affects how the brain works. Determining the prevalence of TBI, including concussion, in the United States is difficult. Surveillance of TBI in the United States has historically relied on healthcare administrative datasets. The most recent numbers find that about 214,000 Americans are hospitalized and 69,000 Americans die from a TBI every year. However, these numbers likely undercount the true burden of TBI as they do not include people who seek care for their injuries outside of hospital settings or people who do not seek care. An alternative approach to TBI surveillance is to make use of national self-report surveys that ask respondents to report their experience with head injuries. The Centers for Disease Control and Prevention (CDC) has recently added TBI prevalence questions to several national surveys. The objective of this presentation is to summarize CDC’s recent efforts in TBI self-reporting.
Methods
CDC added various 12-month and lifetime TBI prevalence questions to a series of nationally representative surveys (e.g., Porter Novelli’s ConsumerStyles survey, National Health Interview Survey, Youth Risk Behavior Survey). Each survey’s questions were slightly different, and they varied by time period assessed and whether they focused on adult or youth respondents.
Results
Depending on the survey methodology and question wording used, 12-month prevalence of concussion/TBI among adults ranged from 3-12% while lifetime prevalence ranged from about 21-28%. Twelve-month prevalence of concussion/TBI among children and adolescents was about 10% while lifetime prevalence ranged from 7-14%.
Conclusions
These results demonstrate that TBI is a common health condition in the United States, and one that is likely consistently underestimated by traditional surveillance methods, which rely on hospital-based datasets. Allowing respondents to self-report their suspected concussions and TBIs resulted in larger prevalence estimates than those captured via traditional surveillance methods. Analysis of the various surveys shows that how the questions are asked, and what terminology is used (e.g., concussion vs. mild traumatic brain injury), affects the estimate. CDC has used the data collected to better refine the questions added to the surveys to ensure the most accurate prevalence estimates are being obtained. These data can be used to optimize and standardize data collection approaches across the field of TBI surveillance.
25 Factors Related to the Quality and Stability of Partner Relationships After Stroke: A Systematic Literature Review
Boudewijn Bus1,2; Brenda van den Broek1,2,3; Laura Verrijt1; Sophie Rijnen1,2; Caroline van Heugten2,3,4
1Multidisciplinary Specialist Centre for Brain Injury and Neuropsychiatry, GGZ Oost-Brabant, Huize Padua, the Netherlands; 2Limburg Brain Injury Centre, Maastricht University, Maastricht, the Netherlands; 3School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands; 4Department of Neuropsychology and Psychopharmacology, Maastricht University, Maastricht, the Netherlands
Objective
Provide an overview of the current state of knowledge on factors related to relationship quality and stability following stroke.
Data Sources
Cumulative Index to Nursing and Allied Health, Embase, MEDLINE, Psychology and Behavioral Sciences Collection, APA PsycINFO, and PubMed were searched on November 15, 2022, for literature on factors associated with (1) relationship quality and (2) relationship stability after stroke.
Study Selection
English quantitative and qualitative studies investigating factors associated with relationship quality and/or stability after stroke were included. Three reviewers independently assessed eligibility. Consensus meetings were held in case of divergent opinions. Forty-four studies were included
Data Extraction
Information regarding study objectives and characteristics, participant demographics, independent and dependent variables, and main findings was extracted. Study quality was rated using the JBI Checklist for Analytical Cross-Sectional Studies and/or the CASP Checklist for Qualitative Research. Both were performed by the lead reviewer and checked by the second reviewer. Identified factors are described and presented according to the domains of the International Classification of Functioning, Disability, and Health model.
Data Synthesis
Thirty-seven factors related to relationship quality after stroke were identified, covering the domains of body functions and structures (e.g., cognitive problems), activities (e.g., decrease of physical intimacy), participation (e.g., being socially active), environment (e.g., medication side effects), and personal factors (e.g., hyper-vigilance). Eight factors related to relationship stability were identified, covering the domains of participation (agreement on reciprocal roles) and personal factors (e.g., quality of pre-stroke relationship).
Conclusions
Relationship quality and stability after stroke are related to a multitude of factors. Future research should confirm the relevance of factors found in few studies of suboptimal quality, explore possible associations between relationship stability and factors falling in the domains of body functions & structure, activity, and environmental factors, and explicitly explore potential positive effects of stroke on relationships.
26 The Role of Whiplash Associated Disorders on Concussion Recovery: A Retrospective Study.
Stéphanie Flageol1,2; Evan Foster2; Paul Comper2; Mark Bayley2,3; Tharshini Chandra2; Alan Tam2,3
1IRDPQ, Quebec, Canada; 2Toronto Rehabilitation Institute, University Health Network, Toronto, Canada; 3Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Canada
Objectives
Examine the effect of whiplash associated disorders (WAD) on concussion outcomes among adults evaluated within 7 days of injury.
Setting
The study was carried out at the Hull-Ellis Concussion and Research Clinic (Toronto Rehabilitation Institute, Canada).
Methods
The authors analyzed patient’s clinical charts and routinely collected data from individuals that were admitted to the clinic between July 2019 and March 2020 from one-week to eight-weeks post-injury. The presence of WAD was determined by the presence of neck pain and cervical spine tenderness or restricted range of motion on physical examination by a clinic physician. Patients’ characteristics and outcomes were described according to the presence or absence of concomitant whiplash associated disorders (WAD).
Results
82 medical files were reviewed retrospectively. 19 cases were excluded due to missing data and 63 cases were included in the study. 25 (40%) patients included were deemed to have a concurrent WAD. The WAD group presented with higher symptom severity (mean of 59/132 (SD 32) versus 39/132 (SD 26) for the no WAD group) and number of symptoms (mean of 18/22 (SD 5) versus 15/22 (SD 6) for the no WAD group) on the SCAT5 on initial assessment. By the end of the follow-up (eight weeks post-injury), fewer individuals with WAD had recovered from their concussion than those without WAD (44% with WAD versus 66% without WAD).
Conclusion
Our findings show that the combination of both concussion and neck symptoms can result in an overall greater frequency and intensity of initial symptoms, and a longer duration is required for recovery of all injury-related symptoms. Recognition of cervical injury in tandem with a diagnosed concussion soon after injury may facilitate earlier referral to appropriate rehabilitation.
27 American Congress of Rehabilitation Medicine Disorders of Consciousness Family Education Project: Implementation and Dissemination of New Web-Based Resource for Caregivers
Brooke Murtaugh1; Kathryn Farris2; Shanti Pinto3; Amy Shapiro-Rosenbaum4; Susan Johnson5
1Madonna Rehabilitation Hospitals, Lincoln, United States; 2Shepherd Center, Atlanta, United States; 3UT Southwestern, Dallas, United States; 4Park Terrace Care Center, Queens, United States; 5Georgia RSVP Clinic, Atlanta, United States
There is an array of educational material available to families and caregivers of severe brain injury experiencing Disorders of Consciousness (DoC). However, it is difficult to find information that is accurate and easy to navigate. Families and caregivers experience trauma along a continuum from hospital to community (Cameron and Gignac 2008). The need for caregivers to prepare for changes in role and caring for their loved one evolves over the course of recovery, but often not fully addressed by their clinical care team. This can lead to added stress, ambiguity and compound trauma for family and caregivers. The American Congress of Rehabilitation Medicine (ACRM) Brain Injury Interdisciplinary Special Interest Group: DoC Task Force, Family Education Subcommittee has developed a compendium of shared educational resources. During the last seven years, the committee engaged in an environmental scan of existing family education content from providers and websites that had information specific to DoC. We then developed a structure for delivering information that is simple, easy to read and organized in a way that that families/caregivers can find specific information across the course of recovery all located in a central, accessible location. The organization of content is separated into three sections: Body/Mind, Taking Care of Self and Resources. Focus groups and surveys were completed with 22 families and 16 professionals to validate the overall structure and included content for accuracy and health literacy. Consumer and professional survey responses were analyzed. Results of the family surveys 67-100% of respondents found content was easy to understand, descriptive and prompted end users to further engage with the additional website links embedded into the content. Professional surveys resulted in 100% of respondents approving the overall content included. The final product of family-focused DoC education will be accessible within a Treatment Hub on www.BrainLine.org. This poster will highlight the overall evolution of the project, content, the review process, partnership with BrainLine.org and the funding efforts to build the Treatment Hub and BrainLine. Our objective is to facilitate knowledge translation of this web-based resource to support further dissemination to the family end user experiencing acute and chronic DoC. Implementation to support utilization of this educational resource, by families, will be dependent on expanding knowledge and collaboration with brain injury medicine professionals across the care continuum for persons experiencing DoC.
28 A Case Report of Arachnoiditis in a Stroke Patient
Shubhangi Kumar, Physical Medicine and Rehabilitation PGY31 Kaitlyn Brunworth, M.D.1; Assistant Professor Gemayaret Alvarez1
1Nova Southeastern University, Davie, United States; 2University of Miami/Jackson Memorial Hospital, Miami, United States
This is the case of a 48-year-old female with a past medical history of hypertension who presented to the emergency room with “the worst headache” of her life. She was found to have diffuse subarachnoid hemorrhage and left frontal intraparenchymal hemorrhage, requiring ventriculoperitoneal shunt placement. After the procedure, the patient complained of new-onset bilateral lower extremity paresthesias and weakness. Lab results ruled out cobalamin and folate deficiencies. Electrodiagnostic studies showed bilateral lumbosacral root dysfunction primarily affecting L5-S2. Lumbar MRI showed clumping and diffuse enhancement of cauda equina nerve roots. These findings raised concern for possible arachnoiditis. Arachnoiditis is defined as a persistent inflammation of arachnoid mater that involves membrane thickening, dural adhesions, and clumping of nerve roots. It has no well-defined epidemiology and is considered quite rare and difficult to diagnose. Potential causes for arachnoiditis range from physical or chemical irritants such as injections, surgery, infectious causes such as HIV or TB, or mechanical irritants such as subarachnoid hemorrhage. It has variable timing from the onset of injury until clinical manifestations appear and presents with varying imaging results. Clinically, patients present with an insidious onset of chronic and debilitating pain, most commonly back pain, progressing to radicular pain and sensory defects. Arachnoiditis is managed with supportive care such as physical therapy, pain medication, muscle relaxants, and neurostimulation. It often goes unrecognized and untreated because it is exceedingly rare and difficult to diagnose. Understanding the causes of arachnoiditis and detecting the signs on imaging and physical examination is important to cultivate treatment regimens for future patients. With supportive management through medication and physical therapy, our patient has shown improvement in symptoms and functionality.
29 Characterizing Genetic Risk Factors for Post Traumatic Epilepsy Following Combat Brain Injury
Justin Weppner1,2,3; Jerry Zhang4; Erica Fan5; Nabil Awan6; Mark Linsenmeyer7; Yvette Conley8; Jordan Grafman9; Amy Wagner4,10,11,12
1Carilion Clinic Brain Injury Center, Roanoke, United States; 2Virginia Tech Carilion School of Medicine, Roanoke, United States; 3Edward Via College of Osteopathic Medicine, Blacksburg, United States; 4Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, United States; 5Department of Epidemiology, University of Pittsburgh, Pittsburgh, United States; 6Department of Biostatistics, University of Pittsburgh, Pittsburgh, United States; 7Sunnyview Rehabilitation Hospital, Schenectady, United States; 8Department of Health Promotion, University of Pittsburgh, Pittsburgh, United States; 9Shirley Ryan Ability Laboratory, Northwestern University, Chicago, United States; 10Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, United States; 11Department of Neuroscience, University of Pittsburgh, Pittsburgh, United States; 12Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, United States
Introduction
Posttraumatic epilepsy (PTE) is a significant concern after traumatic brain injury (TBI), particularly in military contexts. This study investigated genetic risk factors associated with PTE following combat brain injury using a Gene Risk Score (GRS) approach, utilizing data from the Vietnam Veterans Head Injury Study (VHIS) cohort.
Methods
We included 120 genotyped subjects with penetrating TBI (pTBI) and known PTE status monitored over a 35-year period. DNA samples were genotyped for 20 single nucleotide polymorphisms (SNPs) across nine genes linked to PTE in civilians with moderate-to-severe TBI (msTBI). SNPs were assessed using iPLEX Gold or TaqMan Assay, with double-masked genotype assignments. Covariate adjusted logistic regression was used to identify SNP associations with PTE. Covariates included education, post-traumatic stress disorder (PTSD), race, pre-injury intelligence (AFQI), pTBI-related surgery, loss of consciousness (LOC), and pTBI-related amnesia. A weighted gene risk score (wGRS) was then calculated for each individual based on beta-weights derived from univariate logistic regressions generated for each SNP located within individual genes, reaching a p=0.10 threshold in its association with PTE. Ridge regression was used to generate beta-weights for threshold associated SNPs located in the same gene (e.g. IL-1β). This wGRS was used in multivariate logistic regression to assess its added value, above covariates alone, in characterizing PTE risk.
Results
Among this cohort, 44.1% experienced PTE over the 35-year follow-up period. Covariate adjusted logistic regression showed threshold associations between four SNPs (rs16944, rs1801131, rs1143634, and rs769391) and PTE status. For the IL-1β SNP rs16944, AA hom*ozygotes had an 80% PTE rate compared to 30-40% in G-carriers. TT hom*ozygotes for the MTHFR SNP rs1801131 had a 50% PTE rate. Heterozygotes had lower PTE incidence for the IL-1β SNP rs1143634 and for the GAD1 SNP rs769391. A higher number of risk genotypes was positively associated with greater seizure incidence; those with four risk genotypes had a >80% 35-year incidence of PTE while individuals with only one risk allele had ~30% PTE incidence. The wGRS was significantly associated with increased risk for PTE at 35 years, with an odds ratio of 3.64 (1.77-7.52); P<0.001) and enhanced the area under the receiver operating curve (AUROC) by 11% compared to covariates alone.
Discussion
Key SNP associations—IL-1β rs16944, rs1143634, MTHFR rs1801131, GAD1 rs769391—and the GRS enhanced PTE risk assessment beyond covariate factors alone. This wGRS-based approach showcases the cumulative genetic influence on PTE susceptibility among individuals with combat pTBI.
Conclusion
The study highlights genetic contributions to PTE risk after combat TBI. wGRS inclusion significantly improved multivariable model performance over covariates alone. Future work should consider GRS incorporation when assessing PTE risk among contemporary combat TBI populations to support early screening, prevention, and management strategies.
30 The Effectiveness of Trazodone for Management of Acute Agitation in Patients With Traumatic Brain Injury: A Retrospective Chart Review
Kian Nassiri1,2; Sangeeta Driver1,2
1Shirley Ryan AbilityLab, Chicago, United States; 2McGaw Medical Center of Northwestern University, Chicago, United States
Background
Acute agitation is a common complication in patients who have sustained traumatic brain injury (TBI) and can be measured using the Agitated Behavior Scale (ABS), a validated tool that drives clinical management. There is no consensus regarding use of as needed agents for pharmacologic management of acute agitation in people with TBI.
Objectives
The primary objective of this study is to assess the effectiveness of as needed trazodone on reduction of agitation as reflected by lower ABS scores in patients with TBI and to demonstrate consistency in reduction of score across various demographic factors of patients with TBI.
Design
A retrospective chart review was performed of patients admitted to acute inpatient rehabilitation over a 2-year period, who had age > 18 years old and were diagnosed with TBI. Data collected included: demographic information, length of stay, number of trazodone administrations, and pre-/post-trazodone administration ABS scores. Patients were organized into subgroups based on demographic characteristics.
Results
The mean change [CI] in ABS score and total percent change in ABS score for all 128 patients were 8.2 [7.6, 8.8] and 14.6% [13.6%, 15.7%], respectively. For gender, males represented 84.4% (N=108) and females 15.6% (N=20). Mean change and percent change of total ABS based on gender were as follows: males 8.1 [7.4, 8.7] and 14.4% [13.3%, 15.6%], and female 8.7 [7.0, 10.3] and 15.5% [12.5%, 18.4%]. ANOVA showed no significant variance in mean change of ABS based on gender (p=0.51). For race, white represented 52.2% (N=67), black 19.5% (N=25), other 8.6% (N=11), and patients who declined to answer 19.5% (N=25). Mean change and percent change of total ABS based on race were as follows: white 8.3 [7.6, 9.1] and 14.9% [13.5%, 16.3%], black 7.9 [6.3, 9.4] and 14.0% [11.3%, 16.8%], other 8.5 [6.7, 10.2] and 15.1% [12.0%, 18.2%], and declined to answer 8.4 [6.3, 9.6] and 14.2% [11.2%, 17.0%]. ANOVA showed no significant variance based on race (p=0.91). For mechanism of injury, falls represented 46.9% (N=60), motor vehicle collision (MVC) 32.8% (N=42), gunshot wound (GSW) 6.3% (N=8), blunt force trauma (BFT) 9.4% (N=12), and other 4.7% (N=6). Mean change and percent change of total ABS based on mechanism of injury were as follows: falls 8.4 [7.5, 9.3] and 15.0% [13.3%, 16.6%], MVC 7.5 [6.5, 8.4] and 13.4% [11.7%, 15.6%], GSW 7.2 [4.9, 9.4] and 12.8% [8.9%, 16.8%], BFT 10.0 [7.9, 12.2] and 17.9% [14.1%, 21.8%], and other 8.7 [4.8, 12.6] and 15.6% [8.6%, 22.5%]. ANOVA showed no significant variance in mean change of ABS based on mechanism of injury subgroup (p=0.20).
Conclusion
Use of as needed trazodone was associated with consistent reduction in ABS scores of people with TBI, independent of subgroup characteristics based on age, gender, race, and mechanism of injury.
31 Enhancing Interdisciplinary TBI Treatment for Military Veterans and Service Members With Co-Occurring Substance Use: Program Development, Access to Care, and Early Treatment Outcomes
Katherine McCauley1; Tracey Wallace1; Dina Forehand1; Javier Palacios1; Jackie Breitenstein1; Russell Gore1
1Shepherd Center, Atlanta, United States
Background
Traumatic brain injury (TBI) and problems related to substance use (SU) commonly co-occur in the military and veteran population. Individuals with co-occurring TBI and SU (TBI + SU) are at greater risk for multiple negative outcomes, including death by suicide. Intensive interdisciplinary treatment for TBI can support improvement in symptoms and quality of life, but individuals using substances are often denied access to TBI treatment until they maintain lengthy periods of abstinence.
Method
Our interdisciplinary treatment program for military TBI has undertaken efforts to: 1) characterize substance use among those seeking treatment, 2) develop and implement an approach to assessment, integrated treatment, and follow-up support for TBI + SU, and 3) evaluate access and treatment outcomes. We categorized all individuals who inquired about or applied for care within a 26-month period according to level of care accessed or reason for no access. Among 160 participants consented, 101 started intensive outpatient treatment (IOP) for TBI and completed measures related to substance use in addition to assessments for clinical care. This group was divided based on scores on SU-related measures into TBI (n = 59) and TBI + SU (n = 42) groups. Mixed ANOVAs were conducted to determine effects of treatment and group membership on TBI symptoms and consequences related to SU, captured by scores on the Neurobehavioral Symptom Inventory (NSI) and the Short Inventory of Problems - Revised (SIP-R).
Results
An integrated care model of TBI treatment for clients with co-occurring SU was developed by modifying programing and adding resources to help those with TBI + SU safely and effectively participate in interdisciplinary TBI care. There was a significant main effect of treatment (F(1, 100) = 64.37, p < 0.001) on NSI scores, with decreased symptoms at discharge across both groups. Between-group differences were not significant, indicating that groups had similar NSI score reductions with treatment. There was a significant main effect of treatment F(1, 100) = 18.45, p < 0.001 and group membership F(1, 100) = 21.41, p < 0.001 and a group x time interaction F(1, 100) = 9.34, p = 0.003 on SIP-R scores, showing higher SIP-R scores among the TBI + SU group prior to treatment and greater reductions in SIP-R scores for the TBI + SU group with treatment. Among research participants who engaged in IOP treatment during this timeframe (n = 101), four were early discharges, and one of these instances was related to substance use.
Conclusions
This programming has enabled entry and retention in treatment for many clients with TBI + SU. Initial results related to treatment outcomes are promising, with follow-up data collection ongoing. Lessons from these efforts may inform programming in other interdisciplinary programs treating individuals with TBI + SU.
32 OculoMotor and Vestibular Endurance Screening (MoVES) Protocol Adult Concussion Data
Chang Yaramothu1; Jacqueline Theis2; Stuti Mohan1
1New Jersey Institute Of Technology, Newark, United States; 2Virginia Neuro-Optometry, Richmond, United States
Purpose
To evaluate the effectiveness of the OculoMotor and Vestibular Endurance Screening (MoVES) protocol in identifying concussed adults.
Methods
Participants between the ages of 18 to 65 years old were recruited from the Virginia Neuro-Optometry and were referred to the clinic after a concussion diagnosis. Data were collected in the first visit following the MoVES protocol with the following seven assessments: 1) near point of convergence (NPC), 2) amplitude of accommodation for both eyes (AA),3) horizontal saccades, 4) vertical saccades, 5) vergence jumps, 6) horizontal vestibular oculomotor reflex (VOR), and 7) vertical VOR. The OculoMotor Assessment Tool (OMAT, Gulden Ophthalmics, Elkins Park, PA, USA, product number 18009) was utilized to provide eye movement targets for all assessments. Saccadic and vergence jump assessments were performed using methods described in the OMAT Normative study, and NPC/AA were performed utilizing methods described in CITT studies. VOR assessments were performed with the participant holding the larger slider of the OMAT tool at arm’s length and rotating the head horizontally or vertically while fixating on the target letters on the slider. The saccadic, vergence, and VOR movements were performed for one minute each, and the number of repetitions was counted by an operator utilizing the OMAT companion smartphone application. The OMAT smartphone app displayed the number of eye movements or head turns performed in one-minute in 15-second intervals.
Results
Presented data was collected on 33 participants (6 males) with an average age of 39.1 ± 12.3 years and an average of 22.1 ± 34.0 months since injury (3 participants were seen 109, 123, and 126 months after injury). On average, the participants made 24.8, 22.5, 19.0, and 17.2 horizontal saccadic eye movements in each of the 15-second intervals. A similar trend of decreasing number of eye movements or head rotations was observed in all the movements: vertical saccades (24.0, 18.1, 15.2, 12.6), vergence jumps (15.2, 13.1, 11.4, 10.5), HVOR (25.0, 21.6, 19.3, 13.6), VVOR (24.6, 20.4, 19.2, 14.6). The average NPC break was 10.5 ± 7.9 cm with a recovery of 14.9 ± 10.6 cm. The number of eye or head movements presented by this cohort was significantly lower than that observed in normative non-concussed cohorts in previous studies.
Conclusions
These data indicate that the MoVES protocol can potentially be utilized to identify a concussive event in the adult population. Additionally, the MoVES protocol has the potential to be used as an objective quantitative tracking tool for recovery. Healthy controls show no statistical significance in the number of eye or head movements; however, concussed individuals show a consistent decrease in the number of eye or head movements in the first to last interval.
33 Vision Quality of Life With Time (VisQuaL-T) Survey Adult Concussion Data
Chang Yaramothu1; Jacqueline Theis2; Stuti Mohan1
1New Jersey Institute Of Technology, Newark, United States; 2Virginia Neuro-Optometry, Richmond, United States
Purpose
To evaluate the effectiveness of the Vision Quality of Life with Time (VisQuaL-T) survey in assessing the visual quality of life in concussed adults.
Methods
Participants between the ages of 18 to 65 years old were recruited from the Virginia Neuro-Optometry and were referred to the clinic after a concussion diagnosis. Data was collected on the first visit, where the participants responded to the 10 questions in the survey. The survey consisted of a list of the following activities: 1) reading for pleasure, 2) studying for a test/exam, 3) completing homework, 4) completing work in an office setting, 5) being in a crowded location, 6) tolerating habitual lighting, 7) using a smartphone/tablet, 8) playing a computer/console video game, 9) using a computer for general purposes, 10) watching a show on a large screen. Participants were asked to indicate how long it took them to experience any of the following symptoms: headache, dizziness, eye strain, double vision, floating words, blurry vision, inability to pay attention, easily distracted, or sleepy/drowsy. The possible time ratings, a novel feature of VisQuaL-T, were 0-15 min, 15-30 min, 30-45min, 60+ min, and N/A (for activities a participant does not participate in). A composite score between 0 and 3 was derived utilizing the methods in the VisQuaL-T normative manuscript by Dungan Et al. 2023.
Results
Presented data was collected on 40 participants (6 males) with an average age of 39.2 ± 12.4 years and an average of 21.8 ± 33.3 months since injury (4 participants were seen 98, 109, 123, and 126 months after injury). Participants had an average composite score of 1.56 ± 0.57.
Conclusions
An average composite score of 1.56 is equivalent to approximately 20 minutes. Prior studies have shown that the general population scores an average composite score of 2.4. The utilization of time as a measurement factor has the potential to illicit more concise and quantitative data from a concussed individual. The presented instrument can potentially be more clinically relevant as questions examine how long a patient can perform a task before the onset of symptoms rather than simply reporting whether symptoms are present. This non-generalized symptom scale may potentially be a better indication of their quality of life. The VisQuaL-T can potentially indicate quality of life problems in patients after a concussive event and potentially guide clinical intervention. The survey also has the potential to be used as a recovery tracking tool.
34 Are We Providing Older Persons After Brain Injury the Same Care as Younger Persons? A Retrospective Population-Based Study
Narhari Timilshina1; Arman Ali1; Laura Langer1; Judith Gargaro1; Mark Bayley1
1University Health Network, Toronto, Canada
Introduction
Traumatic brain injury (TBI) is a major public health problem resulting in hospitalizations, morbidity, and mortality globally. Despite the large proportion of elderly persons experiencing TBI, limited data exist at the population level.
Objectives
To apply quality indicators (QI) to examine TBI care quality for older persons (65 years and older).
Methods
Provincial administrative health services data from publicly funded healthcare were used. We co-developed 12 QIs with healthcare partners and persons with lived experience, and measured care quality for patients 65+ years with TBI between 2016 and 2021. Age and gender adjusted incidence and QIs with 95% confidence limits were calculated. Variations in QI performance was explored according to age group, sex, geographic region, and income quintile.
Results
A total of n=15,194 complex-mild and n=19,237 moderate/severe brain injury cases were identified between 2016-2021. The age and gender adjusted incidence rate for all severities of TBI increased with age. Older persons were more likely to get admitted to general rehab than specialized TBI rehab after discharged from acute care (8.35% vs 3.04% for persons with moderate to severe TBI). Higher ED visits rates in years 1 and 2 increased with age (156.8 per 100 PY in 80+ age group vs. 114.9 per 100 PY in 65-79 years age) group). The rate of falls in the first two years after moderate-severe TBI was higher among elderly patients (43.7 per 100 PY in 80+ age group vs. 30.6 per 100 PY in 65-79 year group).
Conclusion
This study establishes a foundation for quality-of-care assessments and monitoring disparity in care for older adults with TBI at a population level. Gaps were identified in receiving rehabilitation services after discharge from acute care, and follow-up with health professionals. Ensuring that older persons receive appropriate rehabilitation and community support to reduce falls is necessary to maintain independence in the community.
35 Short-Term Changes in Primary Motor Cortex Intracortical Inhibition Following Head Impact Exposure in Varsity Canadian Football
Géraldine Martens1,2; Sophie-Andrée Vinet2; Samuel Guay1,2; Amélie Apinis-Deshaies2; Johan Merbah2; Betrand Caré2; Laurie-Ann Corbin-Berrigan3; Eric Wagnac4; Louis De Beaumont1,2
1University Of Montréal, Montréal, Canada; 2Montreal Sacred Heart Hospital Research Center, Montréal, Canada; 3Université du Québec à Trois-Rivières, Trois-Rivières, Canada; 4École de technologie supérieure, Montréal, Canada
Repetitive head impacts and sport-related concussions are significant concerns in contact sports due to their potential adverse effects on brain health. This study investigated the association between head impact exposure (HIE) during varsity football games and short-term changes in cortical excitability of the primary motor cortex (M1) using transcranial magnetic stimulation (TMS). A convenience sample of forty-nine university-level male athletes (median [IQR] age: 23.0 [2.0] years] were recruited. Twenty-nine athletes wore instrumented mouthguards during a football game to measure HIE (head impact group). TMS measurements were conducted 24 hours before and 1-2 hours after the game. Another twenty control football athletes underwent a non-contact training session and underwent identical TMS assessments (control group). For the head impact group, the median [IQR] number of impacts (> 10g) per player during a game was 11.6 [15.0]; the magnitude of each head impact was 18.9 [7.1] g and the cumulative force sustained per player was 234 [312.9] g. TMS results showed that whereas short-interval intracortical inhibition (SICI) ratios increased by 0.054 (± 0.0614) in the head impact group in the hours following the game, it decreased by 0.0704 (±0.0352) in the control group within the same time interval following the non-contact training session. A 2X2 mixed ANOVA on SICI ratios showed a significant Time * Group interaction (F(1, 44) = 5.192, p = .028, η2 = 0.106). Neither the main effect of groups (head impact versus control; p = .058) nor the main effect of time (24 hours before sport vs 1-2 hours after sport; p = 0.756) on SICI measures reached statistical significance. The relationship between HIE (i.e., number, magnitude and cumulative forces of impacts) and SICI was also investigated using two-tailed Pearson’s correlations. SICI modulation following the game was found to be unrelated to the mean number of impacts (p˂ .05) as well as to the cumulative forces of impacts across low-magnitude impact ranges (p˂ .05). However, the observed SICI disinhibition following the game was significantly related to the number of high-magnitude head impacts beyond 40g (r(29)=-0.397, p = 0.041) and the cumulative forces beyond 40g (r(29)=-0.468, p = 0.014) after False Discovery Rate corrections for multiple comparisons were applied. Likewise, this SICI disinhibition strongly correlated with the number of head impacts over 60g (r(29)=-0.629, p < 0.001) and cumulative forces over 60g (r(29)=-0.648, p = 0.014). Athletes exposed to subconcussive hits associated to a football game exhibit abnormal M1 corticomotor inhibition function, particularly when recorded impact magnitude ranges above 40g. Given the deleterious effects of decreased inhibition on motor control and balance, systematically tracking head impact forces at each game and practice with contacts could reveal useful for injury prevention in contact sports.
36 Updating the Concussion Awareness Training Tool (CATT): Translating the Expanding Concussion Evidence Into Accessible Resources
Shelina Babul1,2; Kate Turcotte1; Shazya Karmali1; Vanessa Linton1
1BC Injury Research & Prevention Unit, BC Children’s Hospital, Vancouver, Canada; 2University of British Columbia, Vancouver, Canada
Background
Concussions occur inside and outside of the sports realm – including those resulting from falls, motor vehicle crashes, and violence – yet the emerging concussion response and management evidence is predominantly from the sports perspective. The 6th International Conference on Concussion in Sport, held in October 2022, prompted widespread updating of concussion training and resources. Notably, assessments for concussion, and the roles of rest and aerobic physical activity supporting recovery, have been considerably refined.
Training
The Concussion Awareness Training Tool (CATT) provides free evidence-based concussion training tailored to diverse audiences, extending beyond medical professionals, coaches, youth, athletes, and their caregivers, to include educators, workers, and their employers, and those supporting survivors of intimate partner violence. Recently launched on its new online platform, the CATT offers up-to-date educational eLearning modules and downloadable resources, each created using an integrated knowledge translation approach. CATT resources include the Concussion Pathway (also adapted for the Motion Picture, Film, and Live Performance industry, and for neurodiverse students); questions to ask your doctor; strategies for return to activity, school, school, and work; accommodations during concussion recovery; and considerations for managing mental health symptoms.
Reach
To date, over 175,000 people worldwide have completed CATT training. The cattonline.com website receives over 17,000 visits per month from over 50 countries: primarily Canada and the United States, as well as the United Kingdom, Australia, China, New Zealand, Ireland, India, South Africa, France and elsewhere. This wide-reaching approach to online concussion education, originally launched in 2013, provides information in both English and French. ELearning modules for medical professionals, coaches, and school professionals are also available Arabic. CATT training has been mandated by over 100 sporting associations, universities, schools, and other organizations in Canada and the United States. This includes 32 universities/colleges across Canada, and BC School Sports representing 450 schools in British Columbia. Furthermore, the University of British Columbia is the first medical school in Canada to incorporate concussion education into its curriculum, using the CATT resources.
Expansion
Global education efforts using CATT have focused on East Africa (Uganda, Kenya, Tanzania), Pakistan, Japan, Lebanon, and South Africa. CATT is currently seeking engagement with Indigenous partners within Canada to create culturally appropriate concussion resources.
37 Harnessing Chat-Bot Artificial Intelligence: Assessing the Accuracy and Comprehensiveness of ChatGPT-3.5 and 4.0 in Traumatic Brain Injury Information Dissemination
Matthew Lee1; Angelo Cadiente1; Jamie Chen1; Yi Zhou1,2; Brian Greenwald1,2
1Hackensack Meridian School Of Medicine, Nutley, United States; 2JFK Johnson Rehabilitation Institute, Edison, USA
Objective
Accessibility to accurate and comprehensive information is crucial for patients and caregivers after a traumatic brain injury (TBI). While fact sheets offer standardized information, the rise of chat-bot artificial intelligence (AI) presents an alternative source of information. This study evaluates and compares the accuracy and comprehensiveness of responses from ChatGPT-3.5 and ChatGPT-4.0, utilizing the most-viewed TBI fact sheets from the Model Systems Knowledge Translation Center (MSKTC) as the gold standard.
Methods
Five TBI fact sheets were chosen from the MSKTC based on total views from 12/1/22-5/31/2023. Subheadings from the fact sheets were formatted into questions to simulate real-world queries. These questions were posed to both ChatGPT-3.5 and ChatGPT-4.0. Its output was compared to corresponding MSKTC fact sheet content and was scored by 3 blinded, independent graders using a 1-5 Likert scale based on accuracy, comprehensiveness, and additional factual and useful information. The mode score among graders was used as the consensus score.
Results
Analysis of 38 prompts demonstrated a significant difference in accuracy and comprehensiveness scores between ChatGPT-3.5 and ChatGPT-4.0 (p = 0.04). The mean ChatGPT-4 score was 3.63 (SD = 0.94), indicating its responses were generally accurate but occasionally lacked comprehensiveness. In comparison, ChatGPT-3.5 had a mean score of 3.21 (SD = 0.84), indicating its responses were mostly accurate but often missing key details present in MSKTC fact sheets. The standardized mean difference (SMD) was -0.47 (95% CI: -0.92, -0.01). Further analysis of individual spreadsheets showed that ChatGPT-4.0 outperformed ChatGPT-3.5 in regards to discussing details about the vegetative state, the relationship between memory and TBI and the relationship between headaches and TBI.
Conclusion
This study demonstrates the advancements in AI from ChatGPT-3.5 to ChatGPT-4.0, with the latter showing a statistically significant improvement in accuracy and comprehensiveness when providing information on traumatic brain injuries. While both versions of ChatGPT can serve as valuable tools for disseminating TBI information, ChatGPT-4.0 appears to be a more reliable source, particularly in discussing complex topics like vegetative state and memory-related issues post-TBI. However, caution is advised as occasional gaps in comprehensiveness were observed in both versions. Continued advancements in AI and regular updates based on reliable sources such as MSKTC are essential for optimal patient and caregiver support.
38 Falling Out of Place: An Equity-Focused Characterization of mTBI/Concussion Healthcare
Arman Ali1; Judith Gargaro1; Lesley Plumptre2; Jiming Fang2; Mark Bayley1
1University Health Network (KITE-Toronto Rehab), Toronto, Canada; 2Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada
Introduction
Although often classified as ‘mild’ traumatic brain injuries (mTBI), concussions can have serious public health consequences, with approximately 32,000 people experiencing persisting symptoms in Ontario each year. Due to the lack of a standardized care pathway, care quality and receipt depend on social, geographic, and demographic factors. Concussion treatment in Ontario is provided through a combination of public and third party funded care, the nature of which is determined by the cause of injury. Third party funded care is accessible if injured in an insured motor vehicle collision or at the workplace, while those injured by falls typically only receive publicly or self-funded care. As a result, equity deserving groups are disproportionately affected, impacting the level of care received and recovery. There is little health equity-focused research characterizing the concussion population and their healthcare utilization.
Objectives
To 1) characterize mTBI/concussion and identify inequities related to healthcare utilization, and 2) highlight implications for subpopulations that may be disproportionately impacted.
Methods
Individuals a formal mTBI/concussion diagnosis between 2016 to 2022 were identified using administrative databases (e.g., Discharge Abstract Database, National Ambulatory Care Reporting System, Ontario Health Insurance Plan, and National Rehabilitation Reporting System). Incidence and healthcare utilization rates (e.g., emergency department (ED) visits) were calculated.
Findings
A total of 1,075,791 cases of mTBI/concussion were identified in Ontario. Of this cohort, nearly 30% of people sustained their injury through a fall, while sport-related injuries and motor vehicle collision comprised just 5% and 3% of all mTBI/concussions respectively. The incidence rate of concussion was 1.5 times higher among those with mental health comorbidities (14.07 vs 9.61 per 1000) and nearly 3 times higher among those with cognitive comorbidities (22.44 vs 7.87 per 1000). The ED visit rate during the two years post-concussion was considerably higher in people aged 65-79 (101 visits per 100 patient years (PY))) and 80+ (139.8 visits per 100 PY) compared to the overall provincial rate (79.3 visits per 100 PY). Those in rural or Northern areas, in the lowest income quintile, with pre-existing cognitive comorbidities, and who sustained their injury by falling also had considerably higher ED visit rates compared to the overall rate. The most utilized healthcare resource among people with concussion in the years following their injury was mental health-related care (95.8 per 100 PY).
Conclusion
Concussions occur frequently among older adults and people with mental health or cognitive comorbidities, who are all at greater risk of becoming high users of the healthcare system. Administrative data show that most concussions are caused by falls, which carries important implications, as fall-related injuries are unlikely to be covered by insurance-funded healthcare. Fall prevention efforts should be targeted toward these subgroups to decrease the burden on healthcare systems.
39 How Far are We From Achieving Ideal TBI Care? Evaluating TBI Care Quality and Equity Through Evidence-Based Quality Indicators
Arman Ali1; Judith Gargaro1; Lesley Plumptre2; Jiming Fang2; Mark Bayley1
1University Health Network (KITE-Toronto Rehab), Toronto, Canada; 2Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada
Introduction
Traumatic brain injuries (TBI) are chronic conditions requiring ongoing care. However, the long-term supports needed by people with moderate-severe TBIs are often not in place after inpatient care, despite community living constituting most of their lifetime. This is complicated by the fact that care quality varies tremendously depending on socio-economic and regional factors, often disproportionately affecting equity-deserving groups. Despite these challenges, few jurisdictions have developed care quality evaluation strategies grounded in evidence-based, standardized, and equity-focused care pathways that span the care continuum.
Objectives
To 1) evaluate TBI care quality and equity within the context of the care pathways approach and 2) use Quality Indicator data to identify system-level gaps and target improvement initiatives.
Methods
Residents admitted to acute care with a formal TBI diagnosis between 2016 to 2022 were identified using administrative databases (e.g., Discharge Abstract Database, National Ambulatory Care Reporting System, Ontario Health Insurance Plan, and National Rehabilitation Reporting System). From this cohort, data for 13 Quality Indicators were collected to reflect the stages of the TBI care pathway: pre-acute (n=2 indicators), acute (n=1), rehabilitation (n=3), community (n=7).
Findings
A total of 34,431 incident cases of TBI with hospital stay were identified. Over half of the people with TBI in this cohort were older adults (65+), and nearly 70% sustained their injury by falling. Older adults had a substantially higher incidence rate of moderate-severe TBI (39 per 100,000 for 65–79-year-olds and 173 per 100,000 for those aged 80+) than the overall rate (19 per 100,000). People with pre-existing cognitive comorbidities had an incidence rate six times higher than that for people without such comorbidities (161 per 100,000 vs 26 per 100,000). Admission to inpatient rehab was low across the province, with 22% of moderate-severe TBI patients admitted to any inpatient rehab and only 9% admitted to a specialized facility. For older adults, people with cognitive comorbidities, and people in Northern Ontario, specialized inpatient rehab admission was further limited. Of those who did not receive inpatient rehab, 55% were not followed-up by any medical professional in the community within 30 days of acute discharge. Within one year of acute discharge, just 10% were followed-up by a relevant specialist (e.g., physiatrist).
Conclusion
Care quality and equity gaps were identified in the rehabilitation and community stages of care. Admission to specialized inpatient rehabilitation was extremely limited, particularly in Northern regions, and for older adults and people with cognitive comorbidities, despite the latter groups being at higher risk of sustaining these injuries. Few people with TBI received timely primary care follow-up in the community. It is imperative to target injury prevention and quality improvement efforts toward these inequities and gaps to enhance TBI care quality, improve long-term outcomes, and optimize recovery.
40 How Can We Provide Better Care for Persons Who Have Sustained a Traumatic Brain Injury (TBI)? Living Clinical Practice Guidelines and Clinical Tools Are at Your Fingertips to Ensure Best Care Practice
Aishwarya Nair1; Parwana Akbari1; Judith Gargaro1; Mark Bayley1
1University Health Network, Toronto, Canada
Background
The Canadian Clinical Practice Guideline (CPG) for the Rehabilitation of Adults with Moderate to Severe Traumatic Brain Injury (TBI) helps inform TBI care across jurisdictions through its ongoing and comprehensive review of research and clinical evidence. This review helps the CPG produce best-practice recommendations to improve the quality and consistency of care provided by healthcare professionals, as well as patient health outcomes. The CPG’s beneficial effects, however, are contingent on not only a methodologically rigorous guideline development process, but also on the successful knowledge translation (KT) and implementation of the resulting recommendations and associated tools.
Objectives
Orient healthcare professionals to the CPG and help 1) increase understanding of the clinical value and utility of the living CPG and Ideal Care Pathways, which promote quality care and equity of access across the care continuum, and 2) guide implementation of the up-to-date best-practice recommendations, resources, and clinical tools.
Methods
Regulated Health Professional Associations in Ontario, Canada were approached to partner in and co-develop targeted KT activities rooted in the principles of adult learning: 1) self-concept; evidenced in CPG KT’s self-directed, asynchronous learning model, 2) adult learner experience, readiness to learn, orientation to learning, and motivation to learn; evidenced in CPG KT’s target audience and voluntary attendance, and 3) active learning; evidenced in CPG KT’s real-life case examples presented by healthcare professionals and interactive discussion. The KT activities promoted the relevance of the CPG by using clinical data, partnering with relevant practicing clinicians, and addressing current clinical issues in TBI care. The primary target audience was healthcare professionals who may not routinely encounter individuals who have sustained a TBI, and/or who may not be up to date on TBI best care practices.
Results
The most popular KT method was interactive webinars, but in many cases, multiple methods, including newsletter articles, blog posts, website links and all-member emails, were used. All webinars were recorded, and their slide decks were made available for asynchronous learning. The KT activities have been ongoing since June 2023, and have shown excellent engagement as evidenced in the increasing number of visits to the CPG website, with 7700 visits in July 2023 to 9205 visits in September 2023. Invitations have been forth coming to return for further interactive sessions and to present at relevant RHP conferences. Further data on the CPG KT engagement, follow-up activities, and Google Analytics for the online resources will be presented.
Conclusion
Our multi-faceted and collaborative KT strategy for the CPG and Ideal Care Pathways is key in helping healthcare professionals make informed TBI clinical care decisions based on the most up-to-date scientific evidence for quality care, supporting the overall vision to provide ideal and equitable lifelong care for ALL after a brain injury.
41 “I Am Seen, I Am Heard, I Matter:” A Case Study of a Somatic, Contemplative Approach to Embodied Recovery From Functional Neurological Disorder, Traumatic Brain Injury, and Post Traumatic Stress Disorder Among Special Operations Forces
Esther Estey1,2,3; Carey Pawlowski1; Wendy Guyker3
1Veterans Affairs Palo Alto Healthcare System, Palo Alto, United States; 2Harvard Medical School, Center For Mindfulness, Malden, United States; 3University at Buffalo, The State University of New York, Buffalo, United States
Objectives
Functional neurological disorder (FND) denotes neurological disorders of unknown origin that are not explained by other mental or medical disorders or structural injury to the brain. Symptoms can include motor/sensory loss, seizures, tremors, and other disturbances that affect critical areas of functioning. Traumatic brain injury (TBI) can be a precipitant, along with trauma and Post Traumatic Stress Disorder (PTSD) – both of which may serve as either predisposing or precipitating factors for FND. The prevalence rate of FND is higher among active-duty service members than the U.S. civilian population, with those presenting with a history of mood or PTSD symptoms at greater risk. Emergent findings on clinical treatment integrating cognitive, mindfulness, and compassion-based approaches for FND are promising but limited. There is no current evidence on body-oriented, somatic therapies which may holistically address the range of symptoms causing distress and/or dysfunction for adults with FND.
Methods
A 3-week course of integrative treatment was delivered to a 33-yr old Special Operations Forces, male service member presenting with FND, TBI, PTSD, Generalized Anxiety Disorder, Adjustment Disorder with Depressed Mood, insomnia (clinically significant, in severe range), and chronic pain. The service member received 1-hour psychotherapy sessions, 3 to 4 times per week during an intensive post-acute inpatient brain injury rehabilitation program. Treatment consisted of a somatic and embodiment-based approach integrating cognitive behavioral psychotherapy for PTSD and chronic pain, psychoeducation, body-oriented interventions, mindful movement, meditation, self-compassion exercises, and homework. Repeated measures analyses examined change in pre-post outcomes on the General Anxiety Disorder-7, Patient Health Questionnaire-9, PTSD Checklist for DSM-5, Insomnia Severity Index, Neurobehavioral Symptom Inventory, and Self-Efficacy for Symptom Management Scale.
Results
At post-intervention, there were significant decreases in neurobehavioral symptoms (31 points), PTSD (10 points), anxiety (5 points), and depression (11 points). A significant increase in self-efficacy was also found (30 points). There was a non-significant downward trend in insomnia severity (3 points). Feasibility and acceptability were established.
Conclusions
To our knowledge, this is the first evidence of efficacy, feasibility, and acceptability of third-wave cognitive behavioral treatment with a military service-member, as well as the first evidence for any integrated psychotherapy approach for adults addressing FND, TBI, and PTSD concurrently. Further adding to the literature, this is also the first investigation to demonstrate support for the effectiveness of an embodiment-focused, somatic approach to FND recovery. Further investigations based on experimental designs are needed to expand upon these preliminary findings. Recommendations for future studies and trauma-sensitive, somatic, and compassion-based approaches in intensive rehabilitation of FND and comorbid TBI and PTSD are provided.
42 Spectrophotometric Evaluation of Light Sources that Trigger Photophobia in Patients with Brain Injury and the Corresponding Reduction with Tinted Lenses and/or Environmental Adaptations for Indoors, Outdoors, and Electronic Devices
Jacqueline Theis1,2,3; Joyce Stern4
1Virginia Neuro-optometry, Richmond, United States; 2Concussion Care Centre of Virginia, Richmond, United States; 3Department of PMR, Uniformed Services University, Bethesda, United States; 4University of Richmond, Richmond, United States
Introduction
Photophobia is a common symptom in traumatic brain injury that can persist months and even years post injury. Currently, there is a lack of scientific guidance as to the best method to treat these patients.
Methods
We did a retrospective review of patients presenting post-TBI to a neuro-optometric clinic complaining of photophobia and evaluated what types of light sources they found to be most triggering, as well as which treatment option they found to be most alleviating of their symptoms. We then used a spectrophotometer to measure the spectral irradiance and light intensity of the most common triggers (computer, phone, fluorescent lights, indoor incandescent bulbs, and outdoor sunlight), and the change in irradiance and light intensity when using different tinted lenses, reducing screen brightness, and using an anti-glare computer screen.
Results
Direct sunlight has the highest spectral irradiance over 5x that of indoor lighting and electronics. Unlike sunlight, which had a widespread spectral irradiance over all wavelengths, Indoor fluorescent lights and electronics had small, specific peaks of irradiance. Indoor fluorescent light had peaks of irradiance at 435nm, 490nm, 545nm 585nm, 615nm and 710nm, and electronics on full brightness had peaks at 430nm, 450nm, 485nm, 540nm, 585nm, 615nm, 630nm and 650nm and 710nm which were very similar in wavelength but less intense than fluorescent lights. The intensity of the light outside was 60x more intense than fluorescent lights, and 600x more intense than electronics. Patients were variable in their photophobia triggers, with some noting all light sources as triggers, but the majority of patients only reported a profile of specific triggers (ex: fluorescent lights and electronics). Spectrophotometry of 10 different brands of “FL41” tinted lenses revealed that each tint had different spectral profile in reducing light emitted from the computer even though all are marketed as being effective in “blocking blue light.” Online purchased “blue blockers” that were clear with a slight yellow tint and prescription reading glasses with an anti-reflective coating had slight reduction in light transmission at 444-476nm, and 504-536nm, 556-576nm, 628 and 648nm, but the reduction was not as effective as using an anti-glare computer screen or adjusting the brightness of the computer. The most effective tints in reducing spectral irradiance peaks from fluorescent lights included certain but not all FL41 tints, 50% blue and 81% NOIR but that was not what the patient always said was subjectively their preferred tint for comfort.
Conclusion
Not all patients post-TBI are photophobic to the same light sources. The most cost effective solution is to turn the brightness down on devices and overhead lighting, and if that is not effective try an FL41, blue or NOIR tint if the patient requires it to return to ADLs.
43 Immunologically Mediated Biochemical Injury to the Trigeminal Ganglion by COVID-19 Vaccine Administration: An Understanding for the Pathophysiology of Trigeminal Neuralgia
Christopher Ogunsalu1; Lissa Pinkney-Gayle1; Arif Saqui1
1International Post Graduate College, Montego Bay, Jamaica
The trigeminal neuralgia is a relatively uncommon condition which affects less than 0.5% of the general population. This condition is characterized by episodic attacks of sharp pains which is almost always unilateral in the region of the face with the fifth cranial nerve (CN V) distribution. This attack is triggered by movements of the facial muscles, cold temperature, touch and are spontaneous in nature and has ill-defined etiology.
The purpose of this current work is to positively implicate the administration of the COVID-19 vaccine in the pathophysiology of this facial neuralgia which is not unlike Trigeminal neuralgia. It will as such be reasonable to implicate an immunologically mediated biochemical injury to the trigeminal ganglion as the pathway for the expressed pain.
Since Trigeminal neuralgia has existed in the past long before the introduction of COVID-19 vaccination, it may be reasonable that this condition is called a post-traumatic trigeminal neuropathic pain due to biochemical injury to the trigeminal ganglion sequel to an immunological pathway initiated by COVID-19 vaccine. It must as such be a distinct clinic-pathologic entity from trigeminal neuralgia.
44 Defining Concussion Symptom Trajectories and Rates of Persisting Post-Concussive Symptoms Among Youths
Steve Hicks1; Keith Yeates2; Christina Master3; Rebekah Mannix4; Frank Middleton5; John Leddy6; Deborah Levine7
1Penn State University, Department of Pediatrics, Hershey, USA; 2University of Calgary, Department of Psychology, Calgary, Canada; 3Children’s Hospital of Philadelphia, Department of Pediatrics, Philadelphia, USA; 4Boston Children’s Hospital, Department of Emergency Medicine, Boston, USA; 5SUNY Upstate Medical University, Department of Neuroscience, Syracuse, USA; 6SUNY Buffalo, Department of Clinical Orthopedics and Rehabilitation Medicine, Buffalo, USA; 7Weill Cornell College of Medical Sciences, Department of Emergency Medicine, New York, USA
Concussions involve symptoms that arise following mild traumatic brain injury (mTBI). There is limited understanding about the evolution of concussion symptoms, particularly among children. This limits clinicians’ ability to predict concussion duration, or even define persisting post-concussive symptoms (PPCS). The objective of this study was to characterize the trajectory of concussion symptoms among youths and define the prevalence of PPCS.
This cohort study included 1132 youths, 12-21 years. There were 399 youths with mTBI (enrolled 2.9 ± 2 days after mTBI) and 733 without mTBI. Both groups were recruited at emergency departments and outpatient clinics. The Post-Concussion Symptom Inventory (PCSI) was used to assess 22 concussion symptoms. In total, 2074 PCSI were completed: 1076 uninjured ratings (865 from youths without mTBI, and 211 retrospective estimates from youths with mTBI); 998 longitudinal ratings from youths with mTBI: 390 at enrollment, 351 at 1-2 weeks, and 257 at 1 month. Uninjured ratings were used to determine mean symptom burden in the absence of mTBI. Longitudinal ratings were used to characterize symptoms after mTBI. Incidence of PPCS 1 month after mTBI was assessed with 3 approaches: 1) compared to individual uninjured symptoms; 2) compared to the mean symptom severity of uninjured youths; 3) using one question, “What percentage of normal do you feel?” (>95% at 1 month = recovered).
Participants were 49% male, 77% white, and 9% Hispanic. The majority were in in high school (44%) or middle school (32%), and 69% were athletes. History of headaches (29%), attention problems (30%), and depression (25%) were common. Many (22%) had a prior mTBI. Uninjured youths endorsed 6.7 of 22 symptoms, with a mean symptom severity of 16 out of 132. Following mTBI (n=399), mean symptom severity was 36 at enrollment, 19 at 1 week, and 9 at 1 month. Headache was the most common symptom at enrollment (88%), 1 week (66%), and 1 month (38%). Difficulty concentrating (33%) was also common at 1 month. One month after mTBI, 35% met PPCS criteria compared to personal uninjured ratings, 25% met PPCS criteria compared to the mean symptom severity of uninjured youths, and 30% met PPCS criteria based on estimated “percent normal.” There was significant agreement between measures (ĸ = 0.62, p < 0.001).
Many youths endorse concussion-like symptoms, even without mTBI. Headache is the predominant symptom in the first month after mTBI. Rates of PPCS in youths are 25-35%, and may be captured with a single self-report question, “What percentage of normal do you feel”
45 Success Is a Journey: Pilot Implementation of the Ideal Care Pathway for Traumatic Brain Injury
Judith Gargaro1; Matheus Joner Wiest1
1UHN-Kite Research Institute, Toronto, Canada
Introduction
There are no evidence-based standardized care pathways implemented at the healthcare system level that provide expert-informed guidance related to care and service provision from time of injury to life in the community, while considering the social determinants of health. Engaging diverse key partners, the Neurotrauma Care Pathways developed Ideal Care Pathways for mild traumatic brain injuries (TBI - concussions) and for moderate to severe TBIs. The TBI Care Pathways address known gaps in care related to, for example, unclear expectations during patient journeys, non-standardized concussion identification, and the much-needed lifelong community supports, especially related to mental health. With the Pathways at hand, it is time to start the journey to address these gaps.
Objective
to describe the process and outcomes of implementation projects addressing key elements of the TBI Care Pathways.
Methods
Provincial Working Groups composed of over 200 people with lived experience (PWLE) and their families, clinicians, healthcare administrators, community service providers, policymakers and researchers met to identify crucial components that constitute ideal care, highlighted system-level gaps, and developed and prioritized companion quality indicators by ranking them on significance and feasibility. Groups set regional and provincial implementation priorities. We identified regional teams to champion the implementation of three projects. Each team received a grant to co-design with persons with lived experience and their families a care map and implementation manual related to the implementation priorities. The projects had to implement an ongoing sustainability plan and evaluation strategies and ground their work in the principles of implementation science.
Results
A set of implementation priorities was established which included two common priorities across the province: education for persons with lived experience and their families, and care coordination and navigation. Out of 6 pilot implementation projects, three involve TBI Care Pathways; these include: 1) a large urban concussion care clinic partnering with the TBI system navigator to optimize referral services; 2) a justice-involved support organization and a TBI system navigator creating a resource list for those living with complex needs, and 3) a community base provider facilitating post-traumatic stress disorder training after TBI. Each group developed the requisite care map, implementation manual, sustainability plan and collected evaluation data specific to their project. The teams presented their work at a provincial summit attended by PWLE and their families, clinical managers, system planners, injury-specific navigators, and funded and government officials to discuss opportunities for scale and spread.
Conclusion
These evidence-based Ideal Care Pathways represent a road map for quality improvement with a strong emphasis on community care and transitions. The implementation projects are initial steps of the journey towards ensuring that all persons living with TBI and their families receive equitable care and supports to address their chronic needs over the lifespan.
46 The Abbreviated Spokane mTBI Exam (aSME): A Potent Tool in Detecting Neurologic Dysfunction From Subconcussive Blows
Grace Wandler3; Reese Beisser1,2; Greg Carter1,2; Valerie Moody1; Reese Beisser2
1University Of Montana, Neural Injury Center, Missoula, United States; 2Providence St. Luke’s Rehabilitation Institute, Spokane, USA; 3Hellgate High School, Missoula, USA
A subconcussive impact is defined as a bump, blow, or jolt to the head that does not manifest any overt clinical symptoms. Such events carry a latent potential for neurological impairment, and thus should be of particular concern in contact sports. Existing assessments for sports-related concussions (SRC) predominantly focus on explicit, self-reported symptoms and more obvious neurological impairments, leaving subtle neurological signs in athletes largely undetected and inadequately assessed. These subtle neurological findings are termed soft signs and represent non-localizing abnormalities within the central nervous system. Growing research illustrates that repetitive subconcussive impacts can lead to consequential neurological outcomes and may ultimately culminate in chronic traumatic encephalopathy (CTE). One study demonstrated acute vestibular dysfunction in female soccer players following a single heading practice. Another study demonstrated white matter changes on diffusion tensor imaging in the brains of high school football players post-season, despite no formal concussion diagnoses. Moreover, multiple studies have shown that athletes deemed clinically recovered from SRC are at increased risk for further injuries; our prior research revealed soft signs of residual neurologic damage in such post-concussed athletes. These findings indicate that the existing SRC evaluations lack sensitivity in identifying residual neurological impairments. The Spokane mTBI Exam (SME) was previously developed by our group as a tool to identify soft signs following mTBI/concussion. In the present study, we used an abbreviated version of the SME (aSME) to screen 19 male amateur boxers, compared to 9 non-contact male athletes, swimmers. Participants ages 9 to 22 were evaluated pre- and post-activity using the following metrics: near point convergence (NPC), saccades, ocular smooth pursuits, vestibular-ocular reflex, finger-to-nose testing (dysmetria), and hip flexor strength. Findings revealed that 14 of 19 assessed boxers exhibited post-activity deterioration in their aSME evaluations, and 10 of these 14 exhibited worsening in multiple metrics. Loss of hip flexor strength, deterioration of NPC, and dysmetria, in that order, were the most common changes noted in the boxers. Two out of 9 swimmers revealed a post-activity deficit in 2 of these metrics, which normalized on repeat testing. In contrast, boxers who exhibited a post-activity deficit in NPC either stayed the same or worsened on repeat testing. The post-activity decreases in hip flexor strength observed in boxers cannot be attributed solely to fatigue because swimmers, following a comparable duration and intensity of exercise, showed either stable or improved hip flexor strength. Our findings substantiate the aSME as a pivotal tool for bolstering diagnostic sensitivity in detecting and tracking subconcussive trauma. By objectively monitoring neurological soft signs, the aSME fosters a refined and targeted approach to post-traumatic assessments, which may be used to guide informed return-to-play decisions in contactsports and potentially pave the way for tailored rehabilitation strategies.
47 The Spokane mTBI Exam (SME): A Neurologic Soft Sign Assessment Tool for Mild Traumatic Brain Injury (mTBI)
Reese Beisser2; Greg Carter1,2; Grace Wandler3; Valerie Moody1; Reese Beisser1,2
1University of Montana, Neural Injury Center, Missoula, United States; 2Providence St. Luke’s Rehabilitation Institute, Spokane, United States; 3Hellgate High School, Missoula, United States
To date, no definitive physical exam has emerged for identifying objective residual dysfunction following mTBI. Because the TBI spectrum involves subtle damage to a diffuse network of neuronal connectivity within the cortex, brainstem, cervical cord, and/or autonomic nervous system, abnormalities cannot always be localized to a focal lesion. Such findings are termed “soft signs,” and may be the only neurologic sequelae from an mTBI. These signs may persist chronically following an injury, latently impacting neurologic function and resilience. However, because the traditional neurologic exam is designed to detect focal lesions, it is often normal in patients affected by mTBI and therefore of limited utility in their diagnosis and management. In the absence of an objective, sensitive examination that assesses soft signs, many clinicians still commonly rely on subjective impressions to identify or exclude mTBI. This leads to diagnostic errors, false expectations about recovery, and limits the effective analysis of treatment interventions. A helpful contribution to this gap in validated assessment methods is the physical and neurologic examination of soft signs (PANESS), which was developed in 1984 as a tool for assessing developmental neurologic conditions in children. The PANESS has been shown to be more accurate at identifying subtle dysfunction after a concussion than the sports concussion assessment tool (SCAT). However, the PANESS does not incorporate newer research on mTBI (e.g., the VOMS), and is not standardized for adults. Considering this, we propose the SME, a soft sign assessment tool that complements the traditional neurologic bedside examination and is specific for concussion/mTBI. It integrates information from medical literature, academic conference presentations, and our research team’s more than 90 years of combined experience evaluating and studying mTBI patients. The SME focuses on identifying visual, motor, balance, and autonomic nervous system soft signs following an mTBI. These selected domains appear to be most vulnerable to damage following craniocervical neurotrauma. This premise is supported by studies on concussed athletes examined with the PANESS, by the work of other authors, and by our own prior and ongoing research evaluating processing speed, reaction time, vision, and hip flexor strength in mTBI patients. An abbreviated subset of the SME (the aSME) has recently shown effectiveness in capturing neurologic changes in subconcussed boxers compared to age-matched swimmers, post-activity. Our clinical experience and ongoing quantitative studies support the validity of the SME as a soft sign exam with the promise of being an effective tool for assessing and monitoring impairments acquired after neurotrauma. Our goal is to continue refining the SME to make it a standardized tool, available to all clinicians who evaluate and treat this complex patient population. Such an exam is necessary to improve diagnostic accuracy, guide treatment interventions, evaluate their efficacy, and assist in outcome prediction.
48 A Scoping Review of Long-Term Prognosis of Cognitive Function in Traumatic Brain Injury (TBI)
Tamami Aida, Shuhei Tateoka, Riho Hirose
1Mejiro University Graduate School of Rehabilitation, Tokyo/Shinjuku/Nakaochiai, Japan
Background
Traumatic brain injury (TBI) has been noted to be a chronic disease state. Uncertainty over predictors of long-term outcomes causes great distress for individuals with disabilities and their families.
Objectives
The purpose of this study was to determine the factors involved in the long-term prognosis of cognitive impairments and the long-term prognosis of each cognitive impairment.
Methods
Long-term prognosis was defined as a state of 5 years or more from injury, and on May 23rd, 2023, we looked through articles from 1990 to May 23rd, 2023. A scoping review of the literature was conducted following the 2018 PRISMA-ScR Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Exclusion criteria were involving participants under 25 years old, not addressing Cerebrovascular Disease (CVD) and TBI, and no mention of cognitive impairments.
Results
A total of 9 peer-reviewed articles were included for review. Factors involved in the long-term prognosis of cognitive impairment were that the severity of cognitive impairment was related with Glasgow Outcome Scale (GOS) and post-traumatic amnesia (PTA) (n= 2), not related with the pre-injury social environment, but with pre-injury intelligence and educational level (n= 2), that there was significant improvement between 1 and 3 years after injury (n= 7), that there was no difference in cognitive ability after 5 and 10 years, and that some subjects have reduced memory and working memory after 10 to 15 years (n= 2). The 10-year group scored worse on NSI total score and Traumatic Brain Injury Quality Of Life (TBI-QOL) Cognitive Concerns-General, the TBI group had more physical and neurological complaints than the non-TBI group, and the neurocognitive characteristics of participants with fewer symptoms of psychological distress were better. They also stated that the prevalence of impairment of simple attention was low, with the majority of patients not impaired by 5 years post-injury, and that working memory impairment was still present at 5 years but improved between 6 months and 1 year post-injury. Visual perceptual impairment was shown to improve mostly between 1 and 5 years, and the majority of patients were free of impairment at 5 years. The prevalence of executive dysfunction was low, with the majority of participants showing no impairment by 5 years after injury, with significant improvement between 6 months and 5 years.
Discussions
Predictors of cognitive impairment due to TBI were prior education level and severity of TBI, with visual perceptual function, attention recovered earlier from onset, and executive function and working memory recovery taking longer. However, the association between symptoms of emotional distress and cognitive function and the fact that TBI patients often have complaints suggest that the possibility that some subjects may experience memory and working memory deficits should be addressed.
51 Using Machine Learning to Discover Traumatic Brain Injury Patient Phenotypes: National Concussion Surveillance System Pilot
Dana Waltzman1; Jill Daugherty1; Alexis Peterson1; Angela Lumba-Brown2
1Centers For Disease Control And Prevention, Atlanta, United States; 2Stanford University School of Medicine, Stanford, United States
Current systems of classifying traumatic brain injury (TBI) frequently result in limitations to care. Clinical trials that use traditional classification schemes for TBI (e.g., mild, moderate, and severe) have failed to optimally translate to effective treatment and recovery in the real world, which may inhibit the discovery of effective therapies that improve outcomes based on more granular clinical profiles. Data-driven, alternative methods of classification may stratify TBI patient subpopulations more accurately for optimal identification and treatment. Data from the Centers for Disease Control and Prevention’s pilot National Concussion Surveillance System (n = 10,130 adults) were analyzed. Respondents who self-reported a head injury in the past 12 months were retained in the analysis (n = 1,364) and were queried for injury, outcome, and clinical characteristics. To identify potential TBI phenotypes among those reporting a head injury, respondents were grouped into clusters based upon 12 TBI signs and symptoms. Gower’s dissimilarity matrix was computed due to the nature of the binary input data (i.e., presence or absence of each sign or symptom). The partitioning around medoids (PAM) algorithm was used to cluster observations. To determine the association between outcomes and phenotypes, separate logistic regressions were run using the phenotype characterized by the least severity (e.g., Phenotype A [“cluster 1”]) as the reference group. The algorithm grouped the respondents into five clusters (TBI phenotypes A-E). Each TBI phenotype demonstrated unique clinical characteristics that corresponded to specific differences in outcomes and unique demographic profiles. Phenotype C represented more clinically severe TBIs with the highest prevalence of symptoms (i.e., >50% of respondents in this cluster self-reported 11 out of the 12 signs/symptoms) and a higher association with worse outcomes when compared to individuals in Phenotype A, a group with few TBI-related signs and symptoms: medical evaluation (odds ratio [OR] = 9.4, 95% confidence interval [CI] = 5.8-15.3), symptoms that were not currently resolved or resolved in 8+ days (OR = 10.6, 95% CI = 6.2-18.1), and more likely to report at least moderate, as compared to no or slight, impacts on social (OR = 54.7, 95% CI = 22.4-133.4) and work (OR = 25.4, 95% CI = 11.2-57.2) functioning. These results demonstrate that machine learning can be used to classify patients into unique TBI phenotypes. Further research might examine the utility of such classifications in supporting clinical diagnosis and patient recovery for this complex health condition.
52 Steps Toward Titrating Educational and Related Service Sessions to Minimize the Occurrence of Seizure-Like Events in a School Setting
Diane Bienek1; Arletis Bueno Martinez1; Ashley Hannon1; Connor Wilson1; Samantha Cotugno1; Rutika Naik1; Caleb Asomugha1; Victor Pedro1
1International Institute for the Brain, New York, United States
Introduction
This case study describes the history of seizure-like events of a 17-year-old Caucasian female diagnosed with spastic quadriplegic cerebral palsy and Lennox-Gastaut syndrome, intractable, with status epilepticus. This individual was enrolled at the International Institute for the Brain (iBRAIN), which establishes and implements an individualized education program (IEP) for each student annually. The student’s 2022 educational plan included mandates of weekly physical (5 h), occupational (5 h), music (2 h individual; 1 h group), and speech-language therapy (5 h). Hearing (0.5 h), vision (3 h), and assistive technology services (1 h) are also included in the student’s plan. For academic sessions, the student participated in a 6:1:1 special education classroom.
Methods
As an academy, iBRAIN does not diagnose seizures. Rather, suspected occurrences were reported as seizure-like events. Information captured from a seizure-like event include, but not limited to, time of day, sensory stimulation and service rendered at time of the event, prior state of arousal, and vital signs during the postictal phase. Pulse rate, respiration rate, and saturated oxygen levels were taken, using an over-the-counter pulse oximeter with respiratory rate device (Item # 793251, Walgreens Boots Alliance, Inc., Deerfield, IL). Herein, we conduct statistical analyses of the reported seizure-like events, considering time of day, sensory stimulation, arousal level, and vital signs.
Results
Within a 16-week period, 38 seizure-like events were reported during this student’s school attendance. The observed frequency distribution of seizure-like events throughout the day was different (P < 0.05) from its expected distribution (i.e., equivalent number of occurrences throughout the day). The occurrence of seizure-like events was influenced (P < 0.05) by the type of sensory stimulation. Altogether, the highest seizure-like event occurrence was (in descending order) during a combination of sensory stimuli, feeding, visual, auditory, and movement. Notably, no seizure-like events were reported when the service sessions were primarily stretching exercises. In sessions where seizure-like events were reported, the mean pulse rate was 22 beats per minute higher (P < 0.05) than when no event was reported. Likewise, the mean number of respirations per minute was higher (P < 0.05) when seizure-like events were reported. Saturated oxygen levels did not differ statistically, when comparing sessions with the presence or absence of seizure-like events.
Conclusion
Understanding patterns of seizure-like events in a school setting could be used to dose or titrate educational and related service sessions. In this case, accommodation for arousal level and increased integration of muscular stretching may be indicated.
53 Factors Influencing Adherence to Insomnia and Obstructive Sleep Apnea Treatments Among Veterans With Mild Traumatic Brain Injury
Adam Kinney1; Lisa Brenner1; Morgan Nance1; Joseph Mignogna1; Audrey Cobb1; Jeri Forster1; Christi Ulmer1; Risa Nakase-Richardson1; Nazanin Bahraini1
1VA Rocky Mountain MIRECC, Aurora, United States
Background
Insomnia disorder and obstructive sleep apnea (OSA) are common co-morbidities among Veterans with mild traumatic brain injury (mTBI). Clinical practice guidelines include recommendations for evidence-based interventions that effectively treat insomnia (e.g., cognitive behavioral therapy for insomnia) and OSA (e.g., positive airway pressure), but clinical benefit depends on Veterans’ consistent adherence to treatment. While adherence to interventions for insomnia disorder and OSA are challenging for many patients, Veterans with mTBI may experience unique barriers worthy of consideration. However, such barriers to adherence are poorly understood in this population. The purpose of this study was to understand factors influencing adherence to recommended treatment for insomnia and OSA among Veterans with mTBI.
Method
Semi-structured interviews (n=49) with 29 clinical stakeholders and 20 Veterans were conducted. Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders. Veterans included those with a clinician-confirmed mTBI with a recent history of insomnia disorder and/or OSA treatment. Themes were identified using a Descriptive and Interpretive approach.
Results
Barriers to sleep disorder treatment adherence included factors associated with the patient (e.g., negative appraisal of treatment benefit), intervention (e.g., side effects), health conditions (e.g., mTBI sequalae), health care system (e.g., limited availability of care), and socioeconomic status (e.g., economic instability). Similarly, facilitators of adherence included patient- (e.g., positive appraisal of treatment benefit), intervention- (e.g., flexible delivery format), condition- (e.g., accommodating cognitive impairments), health care system- (e.g., access to adherence support), and socioeconomic-related factors (e.g., social support).
Conclusions
Interviews revealed the multi-faceted nature of factors influencing adherence to sleep disorder treatment among Veterans with mTBI. Findings can inform the development of novel interventions and care delivery models that meet the complex needs of this population, ensuring they sustain treatment engagement and reap the desired clinical benefits.
54 Iberian Observatory for Disorders of Consciousness
Prof. Liliana Teixeira1,2; Dr. Caroline Schnakers3; Enrique Noe4
1Center for Translational Health and Medical Biotechnology Research, Portugal; 2Center for Innovative Care and Health Technology, Portugal; 3Casa Colina Hospital and Centers for Healthcare, United States; 4IRENEA-Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, España
This poster presents the main goals of the Iberian Observatory for Disorders of Consciousness and what the developers intend to do to ensure the success of this international project.
The high rate of misdiagnosis for people with disorders of consciousness (DoC) is well known and widely reported in the literature. Most of these studies have been carried out in countries where there are validated tools for the assessment of DoC (Childs & Mercer, 1996; Andrews et al., 1996; Gill-Thwaites & Munday, 2004; Schnakers et al., 2009; Wang et al., 2020). The JFK Coma Recovery Scale-revised is the gold standard assessment for DoC and has already been translated and validated in many countries. However, there are still countries where there are no translated or validated assessment tools and/or where there is little knowledge among health professionals about this population. Portugal and Spain are among those countries. Thus, it became imperative to create an observatory that would help to organize research in this field and to shed a light on this spectrum of often forgotten population.
The main aim of this Observatory is to contribute to understanding the reality of DoC in Portugal and Spain, to understand the trajectory of patients’ general state of health, and above all to give visibility to a spectrum of disorders that are little talked about in both countries. By creating partnerships with health institutions, medical and other health professionals’ societies, research centers, and other stakeholders it is hoped to open a path for high quality standard research.
It is also the Observatory’s responsibility to promote international scientific research activities in the area, contribute to the validation of diagnostic tools in Spanish and Portuguese and share knowledge to the community through the organization of short courses as well as by providing support for undergraduate and postgraduate training in this area.
56 Adolescents with a High Burden of New Onset Mood Symptoms after Sport-Related Concussion Benefit from Prescribed Aerobic Exercise
Matthew Castellana1; George Burnett1,2; Andrew Gasper3; Muhammad Nazir4; John Leddy4,5; Christina Master6; Rebekah Mannix7; William Meehan8; Haley Chizuk4,5; Barry Willer1,4; Mohammad Haider4,5
1Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, United States, 2Buffalo Psychiatric Center, Buffalo, United States; 3Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, United States; 4University Concussion Management Clinic and Research Center, UBMD Orthopaedics and Sports Medicine, Buffalo, United States; 5Department of Orthopedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, United States; 6Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, United States; 7Department of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, United States; 8Department of Pediatrics and Orthopedics, Harvard Medical School, Boston, United States
Objective
Sport-related concussion (SRC), a subtype of mild traumatic brain injury (mTBI), is common in adolescents. A common clinical outcome of SRC is the development of new anxiety and depressive mood symptoms, which can impair SRC recovery. This study assesses the effect of early, targeted aerobic exercise treatment versus a placebo-like stretching program on recovery in adolescent athletes who report high and low initial mood symptom burden after SRC.
Methods
Exploratory secondary analysis using data from two randomized trials collected in four outpatient clinic settings. Male and female adolescents (13-18 years) diagnosed with SRC within ten days of injury were divided into low (< 6/24 points) or high (≥ 6/24 points) burden based on self-reported symptoms of irritability, sadness, nervousness and feeling more emotional on a 0-6 Likert scale. The main outcome measure was recovering during the intervention period and incidence of Persisting Post-Concussive Symptoms (PPCS).
Results
Out of 198 adolescents with SRC, 156 (79%) reported a low burden of mood symptoms (mean = 1.2 ± 1.65) and 42 (21%) reported a high burden (mean = 9.74 ± 3.70) before randomization. The effect of intervention (exercise versus stretching) was not significant in the low mood symptom burden group (hazard ratio = 0.767, p = 0.128) and was significant in the high burden group (hazard ratio = 0.290, p = 0.005). This corresponds to a 71% reduction in risk for PPCS in the high burden group. High burden of mood symptoms had a positive correlation with high physical, cognitive and sleep symptoms, and a higher number of abnormalities on physical exam, but did not correlate with participant sex or level of exercise tolerance.
Conclusions
Early prescribed aerobic exercise treatment facilitates recovery and significantly reduces the incidence of PPCS in adolescents reporting a high burden of new onset mood symptoms after SRC and should be considered as part of a comprehensive treatment plan for these patients.
57 Inflammasome Activation in Alzheimer’s Disease Pathology in the Chronic Stages of Traumatic Brain Injury
Erika Cabrera Ranaldi1; Nathan H Johnson1; Nadine A Kerr1; Helen M Bramlett1; Robert W Keane1; Dr. W Dalton Dietrich1; Juan Pablo de Rivero Vaccari1
1University Of Miami, Miami, United States
Traumatic brain injury (TBI) affects millions of individuals annually, resulting in reduced quality of life in patients and substantial financial costs. TBI impacts learning and memory functionality and is a recognized risk factor for the development of Alzheimer’s disease (AD). A key component of the immune response in TBI and AD is activation of the inflammasome. The inflammasome is a multi-protein complex that activates pro-inflammatory cytokines interleukin (IL)-1β and IL-18, through the recruitment of caspase-1 and apoptosis-associated speck-like protein containing a caspase recruitment domain (ASC). Activation results in pyroptotic cell death through cleavage and formation of the GSDM-D pore. We have previously demonstrated that genetic predisposition to AD, utilizing the 3XTg mouse model, significantly exacerbates inflammasome activation in the acute injury phase of TBI and leads to greater cognitive impairment. Furthermore, we showed that inhibition of the inflammasome through use of an anti-ASC therapeutic monoclonal antibody (IC100), was effective in reducing inflammasome activated IL-1β in 3xTg mice after TBI. Our current work investigates the chronic inflammatory response of TBI pathology in familial AD. 5-month-old wild-type (WT) and 3xTg (AD) mice underwent either sham surgery or moderate controlled cortical impact (CCI). At 3-months after surgery, animals were sacrificed and the ipsilateral cortex was dissected, hom*ogenized, and immunoblotted for inflammasome proteins and IL-1β. A Simple Plex assay was completed using cortical lysates to assess neurodegeneration and astroglia reactivity by probing for neurofilament-light (NfL) and glial fibrillary acidic protein (GFAP), respectively. Histology and immunohistochemistry was also conducted on whole brain sections blotted for ASC, NfL, and GFAP. Sections were used to assess cortical and hippocampal tissue loss after injury using volumetric analysis. Our results demonstrate that IL-1β protein remains significantly elevated in the chronic stages after injury in AD animals compared to WT. We also observed a persistent elevation of the inflammasome proteins NLRP3, caspase-8, and ASC in injured AD mice which was not present in injured WT animals. Moreover, there is a chronic increase in NfL expression after TBI, with evidence of ASC co-localization after injury. Interestingly, only injured AD mice demonstrated continued elevation of GFAP. GFAP+ cells additionally demonstrated ASC co-localization in the injured AD mice. Finally, there was a significant loss in total cortical volume and total hippocampal volume in injured AD mice compared to the injured WT mice. In conclusion, we provide evidence that genetic predisposition to AD leads to chronic inflammasome activation and pro-inflammatory cytokine release after TBI leading to even greater neurodegeneration. Importantly, our results indicate that the inflammasome could be a promising therapeutic target for TBI with AD.
58 Salivary Brain-Derived Neurotrophic Factor in Athletes With Acute Sport-Related Concussion Throughout Exercise Intervention
Haley Chizuk1,2; Alexander Rawlings1; Jaffer Sayeed1; Dr. Mohammad Haider1,2; Barry Willer1,3; John Leddy1,2; Praveen Arany
1University Concussion Management Clinic and Research Center, UBMD Orthopaedics and Sports Medicine, Buffalo, United States; 2Department of Orthopedics, Jacobs School of edicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, United States; 3Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, Buffalo, United States, 4Department of Oral Biology, School of Dental Medicine, State University of New York at Buffalo, Buffalo, United States
Objectives
Brain-Derived Neurotrophic Factor (BDNF) mediates the neuronal response to injury. It has been hypothesized that BDNF is a potential biomarker of sport-related concussion (SRC). BDNF expression is exercise-dependent, and aerobic exercise is a standard treatment for SRC. This study assessed salivary BDNF expression in athletes with acute SRC and throughout a 2-week aerobic exercise intervention.
Methods
Athletes with acute SRC (n= 32, 66% male, 15.6 ± 1.4 years) and healthy controls (n= 28, 66% male, 16.0 ± 1.6 years) provided saliva samples weekly (Day 0, 7 and 14). Concussed and control participants were randomly prescribed individualized aerobic exercise at high (5 days/week for 30 minutes) or low volumes (3 days/week for 20 minutes). Prescribed exercise intensity was based on the results from each participant’s graded exercise test. Participants completed standard clinical examinations and symptom reports during each visit. An optimized Enzyme-Linked Immunosorbent Assay (ELISA) for BDNF (R&D systems) was used to assess samples in triplicate.
Results
ELISA standard curves were high quality (healthy r2= 1.00, concussed r2= 0.98). At the initial visit, concussed females had higher salivary BDNF than healthy participants (p=0.002). There was no difference between concussed and healthy males’ BDNF at the initial visit (p=0.627). Over time, concussed females consistently showed higher salivary BDNF expression than healthy females, whereas males were not different. BDNF level was not affected by the volume of exercise participants completed (p=0.767) or by history of prior concussions (p=0.85).
Conclusion
The data suggest that salivary BDNF may be assessed for post-concussion monitoring in adolescent athletes but may be more informative for females. Unexpectedly, exercise volume did not affect BDNF, suggesting that a longer exercise intervention would be required to impact BDNF expression. BDNF levels were not affected by time, regardless of recovery, consistent with reports that physiological dysfunction persists beyond clinical recovery from SRC. In conclusion, salivary BDNF offers a non-invasive and convenient analyte that may aid in concussion diagnosis and for monitoring post-concussion treatment response. However, further research is needed to understand the effects of sex, exercise, and recovery on salivary BDNF after SRC.
Acknowledgment
Support for this project by the Clinical Translational Science Institute at the University at Buffalo (UL1TR001412).
59 Disparities in Trauma-Informed Care: Understanding Mental Health Providers’ Ability to Identify Clients With Traumatic Brain Injury Resulting From Physical Violence
Jack Poon1; Mandisa Keswa2; Julia Stork3; Wendy Wood-Kjelvik, Helene Smith, Nicole Infantino4; Edie Zusman5
1University of Chicago, Chicago, United States of America, 2Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, United States of America; 3Northwestern University, Evanston, United States of America; 4Touro University Nevada, Henderson, United States of America; 5Neuroscience Partners, Palo Alto, United States
Background
Traumatic brain injury (TBI) is a serious medical condition well recognized among veterans and athletes, but less is known about TBI as a consequence of physical violence, particularly domestic violence and intimate partner violence (DV/IPV). An estimated 25% of women and 10% of men in the United States experience DV/IPV during their lifetime, with 74% of individual violent events involving injury to the head, neck or face. Half of these events include strangulation causing hypoxic brain injury. Despite a recent study which found that 58% of women entering DV shelters had sustained one or more concussions from DV/IPV, survivors more often engage with mental health professionals (MHPs) for TBI symptoms such as anxiety, depression, and PTSD than with concussion experts. MHPs have an unique opportunity to recognize TBI in clients who have experienced physical violence or abuse, incorporate an understanding of brain injury into their care programs, and refer to TBI experts as appropriate.
Objectives
The primary objective is to estimate the percentage of MHPs who care for survivors of physical violence in their practice. The secondary objective is to assess among MHPs who care for survivors of physical violence their self-reported comfort and training to recognize signs and symptoms of TBI among their clients.
Methods
A ten question anonymous online survey tool was vetted, validated, and sent to a cohort of U.S. health care professionals inclusive of MHPs affiliated with DV/IPV organizations. The 5-10 minute survey includes respondent demographics and utilizes standard Likert scales to assess self-reported experience, training and comfort in assessing TBI.
Results
Of an estimated 350 surveys sent out, 102 responses were returned with 74 responses sufficiently completed for inclusion in the analysis. While 89.2% of MHPs reported that their clientele includes individuals who have experienced physical violence, only 16.2% of MHPs responded that they felt very comfortable or extremely comfortable in evaluating clients for TBI. 45.9% of MHPs reported receiving no training in TBI assessment; however, 70.2% reported that they are very interested or extremely interested in further TBI training.
Conclusions
While the majority of MHPs reported seeing clients who have experienced physical violence, a population with a high rate of TBI, the results of this study highlight the potential knowledge gap about TBI among MHPs. Given the disparity, it is encouraging that the majority of MHPs reported high interest in further training to recognize the signs and symptoms of brain injury among their clients, suggesting an opportunity to improve trauma-informed mental health services for survivors of DV/IPV.
60 Identifying the Influence of Lung-Related Injuries on Delirium in Traumatic Brain Injury Patients: A National Analysis
Jordan Shin1; Jeffry Nahmias1; Patrick Chen1; Jefferson Chen1; Michael Lekawa1; Lily Nguyen1; Areg Grigorian1
1University of California, Irvine, Department of Trauma Surgery and Surgical Critical Care, Orange,
Introduction
Traumatic brain injury (TBI) is a known risk factor for delirium, a condition associated with prolonged hospitalization and cognitive deterioration. Although the relationship between TBI and delirium is established, a detailed understanding of specific predictors remains limited. Respiratory disorders can significantly influence the central nervous system, with sequelae such as hypoxia, hypercapnia, and respiratory acidosis causing neurologic dysfunction. Therefore, we hypothesize that lung-associated conditions, stemming either from direct injuries or subsequent surgeries will increase the risk of developing delirium in TBI patients.
Methods
The 2017-2021 Trauma Quality Improvement Program database was queried for patients with TBI, excluding for those with pre-existing dementia. TBI patients developing delirium were compared to those without delirium. A multivariable logistic regression analysis was performed to determine predictors of delirium.
Results
Among 155,252 TBI patients, 3,244 (2.1%) developed delirium. Delirium-afflicted patients showed elevated rates of lung injury (25.0% vs 13.3%, p<0.001), severe head trauma (Abbreviated Injury Score ≥ 3) (51.4% vs 37.8%, p<0.001), sepsis complications (3.1% vs. 0.5%, p<0.001) and more commonly underwent pulmonary operations (21.8% vs. 6.6%, p<0.001). The strongest associated risk factors for delirium included functional dependence (OR 2.70, CI 2.43-3.00, p<0.001), intubation (OR 2.33, CI 2.13-2.56, p<0.001), concurrent lung injury (OR 1.21, CI 1.20-1.33, p<0.001) and pulmonary surgery (OR 1.64, CI 1.48-1.82, p<0.001).
Conclusion
Delirium affected approximately 2% of the national TBI population. Our analysis not only reaffirms known predictors but also emphasizes the critical influence of lung-related conditions on delirium onset. Systemic inflammatory response, frequently instigated by lung injuries, might intensify neurological issues, escalating risk of delirium. Recognizing these risk factors is crucial in refining delirium prediction, prevention, and treatment in the setting of TBI.
61 Behavior Analytic Services in Acquired Brain Injury Rehabilitation: Identifying Barriers and Promoting Progress
Megan Heinicke1; Shelby Bryeans1
1California State University - Sacramento, Sacramento, US
Acquired brain injury (ABI) is a major public health concern in the United States (Schiller et al., 2012) and can result in behavioral consequences, such as physical aggression, sexually inappropriate behavior, and refusals, that impede rehabilitation goals and limit independent living options (Heinicke & Carr, 2014). One way to help rehabilitation professionals manage behavioral concerns and in turn increase the efficacy of their services is to include behavior analysts on their treatment teams. Historically, the most prolific practice area for behavior analysts has been autism spectrum disorder and other developmental disabilities (Normand & Kohn, 2013), but behavior analysts are also well equipped to serve ABI survivors (e.g., robust literature base to support their practice, ethical responsibility to individualize treatment, training in single-case experimental designs and repeated measurement; LeBlanc et al., 2013; Mozzoni, 2008). However, only 0.08% of board certified behavior analysts (BCBAs) report ABI rehabilitation as their primary practice area (BACB, n.d.). Therefore, the purpose of this study was to evaluate why limited visibility and recognition of applied behavior analysis remains a critical barrier to workforce development in ABI settings for BCBAs. We asked 12 subject matter experts (i.e., BCBAs currently serving ABI survivors with a history of doing so for at least five years) to describe their experiences regarding their company’s history with behavioral programming, perceived value of including BCBAs on rehabilitation teams, and barriers while working in ABI rehabilitation via semi-structured interviews. Our interviews included 23 questions, and we conducted a thematic analysis using a semantic approach as well as descriptive statistics to analyze the subject matter experts’ responses (Braun & Clark, 2006; 2013). We organized our results into the following domains: employment demographics (e.g., teaming models, other rehabilitation disciplines included on their teams, common behavioral excesses and deficits addressed), company history with behavior analysis (e.g., who advocated for the addition of BCBAs), value (e.g., the value they felt they contributed to their team vs. the perceived value of BCBAs from their team), workplace barriers (e.g., which barriers exist, why those barriers exist, potential solutions), and final thoughts (e.g., advice for behavior analysts). We will discuss how a better understanding of the identified barriers can aid in informing more specific and effective strategies to increase collaboration across rehabilitation disciplines and ABI survivors’ access to behavior analytic services.
62 Be Pain Smart - A New Way to Manage Pain after Traumatic Brain Injury
Regina Schultz1,2; Jennifer Johnson2; Jane Bradshaw1; Raj Anand1; Tejas Kanhere1; Nicole Kennedy1
1Royal Rehab, Ryde, Australia; 2Agency for Clinical Innovation, St Leonards Australia
Chronic pain is a multifaceted health problem which is a recognized concomitant of traumatic brain injury (TBI) that can significantly impact on the achievement of individual goals, social participation, activities of daily living and functional capacity. While the estimated prevalence rate is approximately 50% following moderate to severe TBI, there remains limited research and access to appropriate resources and specialized pain services for this population. The Be Pain Smart (BPS) clinic pilot project was developed to provide specialized pain management consultancy for people with a TBI and/or spinal cord injury (SCI). The BPS clinic provided an interdisciplinary comprehensive pain assessment, pain management plan and support to local clinicians to assist the participants to manage their pain. This state-wide service allowed increased access to pain management healthcare for metropolitan, rural, and regional participants. A sample of 40 BPS participants scores on the Patient Reported Outcome Measurement Information System – 29 (PROMIS-29+) and Brief Pain Inventory (BPI) were compared at baseline and follow-up. High rates of referrals were noted throughout the BPS clinic project period. The 40 participants were predominately male (70%), with a mean age of 48.48 years and on average 6.39 years post-injury. On the BPI from baseline to follow-up, on average the participants reported decreased pain scores (worst pain, and average pain) and on pain interference measures including overall pain interference, and more specific areas of pain interference: general activity, mood, walking ability, normal work, relationships with other people, sleep, and enjoyment of life. 75% of participants reported a clinically significant improvement on their overall BPI pain interference scores. Participants also reported improved scores on the PROMIS – 29+ including a decrease in pain interference and pain intensity, and a decrease in anxiety, depression, fatigue, and sleep disturbance symptoms. Participants also reported improvement on the participation in social roles and activities domain. Overall, 70% of participants reported a clinically significant improvement on their overall pain interference scores. Consequently, these preliminary results from this pilot study provides burgeoning evidence for the effectiveness of the BPS clinics in reducing pain interference for these two complex cohorts. Access to the BPS clinic reduced the level of interference of pain in the lives of TBI participants which lead to additional improvements in other domains, this emphasizes the critical role of an interdisciplinary, patient-centered approach to pain management in this highly complex cohort. The ongoing high referral rate highlights the importance of embedding specialized models of care into existing clinical services to optimize referrals and overall increasing the capacity of the system to manage pain in these populations. In conclusion, a specialized patient-centered, interdisciplinary pain clinic for people with TBI reduced overall pain interference and led to improvements in other key functional domains.
63 Be Pain Smart – Evaluation of Online Clinician Pain Management Education Modules
Regina Schultz1; Tania Gardner2; Jennifer Johnson1
1Agency for Clinical Innovation, Ryde, Australia; 2University of Sydney, Sydney, Australia
There is a growing body of literature aimed at understanding the assessment and management of chronic pain after moderate to severe traumatic brain injury (M/S-TBI). Multidisciplinary (MDT) pain management is accepted as gold standard for chronic pain, but there is limited evidence to guide clinicians on how to modify general pain management strategies for people with a M/S-TBI. The Be Pain Smart – Online Education Modules (BPS-OEM) are a suite of online modules, providing evidence-based training for clinicians on pain management strategies for people with a M/S-TBI. The modules have utilized optimal adult learning principles within the design to support the learning of pain management strategies and clinical decision making aligned with the BPS clinical reasoning framework. The online delivery allows for maximum accessibility to facilitate the training of clinicians across metropolitan and rural/remote regions. The aim of this study is to evaluate the feasibility and acceptability of the BPS-OEM, particularly examining clinicians’ pain beliefs, confidence and clinical practice when managing pain with people who have a M/S-TBI. A sample of allied health clinicians were recruited via advertisem*nts through the relevant New South Wales (NSW) networks. Data was collected via an online survey with outcome measures targeting clinical practice, knowledge, confidence, pain beliefs and clinical value of the BPS-OEM. Results demonstrated improvement in clinician confidence and pain knowledge, and changes in pain beliefs to be more aligned with MDT pain management approaches. The BPS clinical reasoning framework with an online interactive clinical reasoning tool will be presented with accessibility and usability results presented. The authors will discuss how improvements in clinician confidence and pain knowledge will lead to increased capacity within existing services to assess and manage chronic pain in the TBI population. The added value of additional 6 group mentoring sessions to compliment the BPS-OEM will be reviewed. The BPS-OEM provides training and a clinical reasoning framework to assist clinicians to improve access to and the delivery of appropriate pain management services for people with a M/S-TBI.
64 “An Individualized Wallet-Card Addresses Financial Capability Challenges for Adults Living With Acquired Brain Injury: A Longitudinal Qualitative Intervention Pilot Study.”
Lisa Engel1; Roheema Ewesesan1; Kafayat Adedotun1; Celine Latulipe1; Mohammad N. Khan1; Anne Hunt2; Ibiyemi Arowolo1; Frederique Poncet3; Jane Karpa4
1The University of Manitoba, Winnipeg, Canada; 2University of Toronto, Toronto, Canada; 3Chercheure au Centre de réadaptation Lethbridge-Layton-Mackay, Canada; 4Brandon University, Winnipeg Campus, Canada
Introduction
Acquired brain injury (ABI) is associated with financial capability challenges. This includes challenges with financial-related social interactions and remembering financial cues or behavioral strategies. In a previous focus-group study, people living with ABI discussed an individualized financial wallet-card as a novel intervention idea.
Purpose
To develop and explore the feasibility, acceptability, uses, and outcomes related to the use of an individualized financial wallet-card for adults living with ABI.
Methods
We used a longitudinal qualitative intervention design. We recruited 10 adult participants who live with ABI (70% female; 1 to 59 years post-ABI). We co-designed a two-sided wallet card with each participant: one side addressed how others can better help the participant in social financial-related situations, and the other side addressed personal financial reminders or strategies. After co-designing their card, we interviewed participants and sent them copies of their cards in printed/laminated and electronic versions. Participants then completed up to five more interviews about their cards over 15 weeks. Participants had the opportunity to update their cards at the final interview. We analyzed longitudinal interviews and wallet-card content using content analysis.
Results
Participants reported using the printed/laminated card more than the electronic version. There were many similarities across participants’ cards, with almost all participants including information related to living with invisible disabilities. Multiple participants reported the importance of card individualization. Common social cues included were to ask others to provide them time, speak slower, or provide written information. Common personal financial reminders were to focus on their needs before their wants, take time or talk with a trusted other person before making financial decisions, or make and check a monthly spending plan. Most participants reported the card very helpful to addressing some of their financial capability challenges. More reported the social situations side to be more helpful, especially to get the help they needed, with many reporting using the card beyond finance-related social situations. Multiple participants noted the personal financial reminders helped to keep them accountable and make better financial decisions. Two participants noted other people expressing negative attitudes about the card, although this was from family members and not from general community members. Some participants reported not using the card much or forgetting to use the card; for two participants, this tended to be in familiar environments where people knew them well.
Conclusion
The co-designed financial wallet-card is a potential low-cost technology to address some of the financial capability challenges experienced by some adults living with ABI. It was beneficial and helpful to many participants. Individualization of cards was important, as some people had unique contexts. Future improvements to the card would be to improve the official look of the card and increase the efficiency in card production.
65 Chronic Pain and Endogenous Pain Control Mechanisms After Brain Injury
David Clark1,2; Karen-Amanda Irvine2,3; Peyman Sahbaie2,3; Xiaoyou Shi1,2; QiLiang Chen1
1Stanford University, Palo Alto, United States; 2VA Palo Alto Healthcare System, Palo Alto, United States; 3Palo Alto Veterans Institute for Research, Palo Alto, USA
Background
Chronic pain is a remarkably frequent outcome of mild TBI (mTBI). Common syndromes include headache, backache, limb pain and prolonged pain in the context of other injuries. Chronic pain after TBI leads to personal suffering, suboptimal functional recovery and increases exposure to opioids. Recent human and laboratory data suggest that dysfunctional endogenous pain control circuits, particularly those centered in the brainstem, may contribute to these pain problems. We hypothesized that descending pain modulatory circuits and aberrant serotonergic signaling are involved.
Methods
To address the effects of mTBI on descending pain modulation, both rat lateral fluid percussion and mouse closed head models were employed. Pain-related changes were measured using tests of mechanical allodynia in the facial region and hindlimbs. The bright light stress model of headache was used as were injury models including hindpaw incision and tibial fracture. Pharmacologic tools involved systemic, intrathecal and stereotactically targeted injections of selective adrenergic and serotonergic agents as well as neurotoxins such as dermorphin-saporin to eliminate cells expressing mu-opioid receptor. To control the activity of the locus coeruleus and periaqueductal gray matter, virally encoded Designer Receptors Exclusively Activated by Designer Drugs (DREADDs) were administered. Finally, running wheel equipped enclosures were used to study the effects of exercise on endogenous pain control systems after TBI.
Results
We observed that TBI leads to an acute but transient period of pain sensitization characterized by facial and hindlimb allodynia supported by descending signaling through spinal 5-HT3 receptors. After recovery from this sensitization, however, the mice and rats showed profound disruption and plasticity of descending noradrenergic and serotonergic circuits. Maintenance of normal pain thresholds after TBI required the activity of endogenous opioid signaling. In this chronic setting, treatment of the mice or rats with serotonin selective reuptake inhibitors (SSRIs) was effective in restoring endogenous pain control systems and in reducing sensitization after limb injuries. Augmenting descending pain modulation through DREADD stimulation in the locus coeruleus or periaqueductal gray matter provided analgesia in the TBI animals. Finally, exercise beginning days after TBI could restore normal endogenous pain control systems.
Conclusions
Even mild TBI leads to a state of profound and long-lasting disruption of endogenous pain control systems. Pain control centers in the brainstem are central to this phenomenon. The augmentation of serotonergic signaling using clinically available SSRI drugs or exercise seem to be viable options for the restoration of normal endogenous pain control, and translational studies are indicated.
66 Assessment of Stimulated Blink Reflex and Symptoms Over Time in Collegiate Athletes With Sport-Related Concussion
Haley Chizuk1; Mohammad Haider1; John Leddy1; Dena Garner2
1UBMD Orthopedics and Sports Medicine, Buffalo, United States; 2Department of Health and Human Performance, The Citadel Charleston, United States
Purpose
Recovery times for collegiate athletes with sport-related concussion (SRC) range from 2 to 4 weeks. The stimulated blink reflex is abnormal after SRC. This study assessed the blink reflex daily from initial assessment (within 2 days of injury) to recovery and compared it with symptom recovery.
Methods
Prospective cohort. Blink reflex (EyeStat) and Post-Concussion Symptom Scale (max=126) were assessed daily from injury to recovery. Blink reflex parameters: time to ipsilateral blink (latency), contralateral blink (differential latency), initial velocity, time to open, time to close, number of oscillations, and distance traveled (excursion). Associations over time were assessed using regression.
Results
41 SRC (from 36 unique athletes, 20.46±1.50 y/o, 79.5% male, 0.95±1.2 days since injury) are included in analysis. Mean symptom severity at initial assessment was 25.00±17.3 and mean time to symptom resolution was 10.87±7.3 days. No significant correlation over time (i.e. p-value of interaction term of blink reflex parameter with days since injury) was observed between daily symptom severity and differential latency (p=0.097), initial velocity (p=0.150), time to open (p=0.506) and number of oscillations (p=0.228). However, a significant association was found for latency (p=0.016), time to close (p=0.017) and excursion (p=0.012). In all three of these regression models, symptom severity significantly decreased over time (p=0.013, 0.017 and 0.013, respectively) and correlated with individual blink reflex parameters throughout the recovery period (p=0.002, <0.001 and <0.001, respectively).
Conclusion
Certain stimulated blink reflex parameters (latency, time to close and excursions) have a significant association with daily symptom reporting over time, meaning that they are abnormal when athletes report a high number of symptoms and return to baseline when athletes are asymptomatic.
Significance
Identifying patterns on how the blink reflex changes throughout recovery and identifying those that are associated with symptom recovery can help develop algorithms that can use change in blink reflex parameters to predict symptom recovery.
67 Stimulated Blink Reflex Abnormalities Before and After Sport-Related Concussion and Association With Self-Reported Symptoms
Haley Chizuk1; Nadir Haider1; John Leddy1; Dena Garner2
1UBMD Orthopedics and Sports Medicine, University at Buffalo, Buffalo, United States; 2Department of Health and Human Performance, The Citadel Charleston, United States
Purpose
Athletes with sport-related concussion (SRC) have blink reflex abnormalities, and can report combinations of physical, cognitive, fatigue or mood-related symptoms after injury. This study compares blink reflex before and after injury and identifies associations with self-reported symptoms.
Methods
Blink reflex (EyeStat, BlinkCNS) and Post-Concussion Symptom Scale (max=126) were assessed preseason and within 2 days of SRC. Clustering identified High (HS) and Low (LS) symptom groups. Blink reflex parameters: time to ipsilateral blink (latency), contralateral blink (differential latency), initial velocity, time to open, time to close, number of oscillations, and distance traveled (excursion).
Results
Differential latency increased (baseline: 4.28±1.8 vs post-injury: 5.33±3.0 ms, p=0.047) and time to close decreased (34.30±5.6 vs 32.38±4.3 ms, p=0.022) after injury on paired t-test, and there was a trend for significance for latency (p=0.094) and oscillations (p=0.074). HS (n=15, 87% male, 20.8±1.5 years, symptoms=43.3±11.4) had slower initial velocity (4.23±0.7 vs 5.16±1.0 pixel/s, p=0.002) than LS (n=23, 74% male, 20.1±1.4 years, symptoms=13.0±6.3), and there was a trend for significance for excursions (p=0.081). Physical symptoms correlated with latency (rho=-0.28, p=0.026) and oscillations (rho=0.37,p=0.003); cognitive correlated with initial velocity (rho=-0.36, p=0.003) and exclusions (rho=-0.38,p=0.002); fatigue correlated with initial velocity (rho=-0.48, p<0.001), time to close (rho=-0.26, p=0.034) and excursion (rho=-0.49, p<0.001). Mood correlated with differential latency (rho=0.49, p<0.001) and initial velocity (rho=-0.30, p=0.014).
Conclusion
The stimulated blink reflex is abnormal acutely after SRC. Increase in differential latency is suggestive that the contralateral blink reflex arch is less efficient. Decreased time to close with a trend that latency is also faster is suggestive that the blink reflex is excited. The strongest correlations were between increasing differential latency and increasing mood symptoms and decreasing excursions and increasing fatigue.
Significance
The corneal blink reflex is a primitive brainstem response initiated by light, touch, or sound. Technology-assisted objective assessment using a portable blink reflexometer has the potential to aid in SRC diagnosis and validate self-reported symptoms.
68 Iterative User-Centered Design of the SwapMyMood Mobile App: Real-World Clinical Insights
Tracey Wallace1; John Morris1; Rebecca Gartell1; Katherine McCauley1; Russell Gore1
1Shepherd Center, Atlanta, United States
Background
SwapMyMood is an innovative mobile app designed to assist individuals with traumatic brain injury (TBI) in implementing problem-solving and emotion regulation strategies based on the clinically validated Short-Term Executive Plus (STEP) cognitive rehabilitation interventions. SwapMyMood’s genesis stems from experiences of patients undergoing TBI rehabilitation who reported challenges recalling and initiating the STEP program process and strategies, particularly in stressful situations. The app was designed to provide a portable solution that electronically guides users through problem-solving and emotion regulation strategies based on the content of the STEP intervention paper manual. App development followed an iterative user-centered design process involving interviews, surveys, sit-by demonstrations, and take-home testing with participants with TBI and clinical experts, incorporating end-user feedback at every stage of design. Three previous design cycles were completed with input by twelve subject matter experts (SMEs) and 24 people with the lived experience of TBI leading up to the current iteration of the app.
Objectives
To describe usability results of the most recent of user-centered design testing of the recently launched 2023 version (v.1.0.10) of SwapMyMood. Usability testing ensures that the new version is functioning correctly and meets the needs of target users. It also helps identify opportunities for future improvement.
Methods
The study included six military service members/veterans with persistent mild TBI (mTBI) symptoms who were participating in an intensive outpatient TBI rehabilitation program, along with four SME clinicians providing care to one or more of the participants. Two additional SMEs outside the clinical setting also provided feedback. Participants used the app in the clinic, home and community for up to two weeks and completed interviews and surveys regarding their experience with the app. Participants with TBI completed the System Usability Scale (SUS). All participants answered questions on app usefulness and desired features.
Results
All testers rated the app’s design and usability positively. SUS scores indicated high acceptability and usability (M=92.08). Users with mTBI reported an increase in knowledge of the app’s supported strategies following take-home use. All SMEs believed the app could benefit people with TBI and that it could be useful in their own professional practice. Valuable feedback from participants suggested the need to further refine some features to enhance support for users with TBI-associated memory challenges in accessing the app’s interventions.
Conclusion
The iterative user-centered design process for the SwapMyMood mobile app, conducted in a real-world clinical setting, has shown promising results. Users and SMEs are enthusiastic about its potential to support TBI patients in managing their symptoms and enhancing their quality of life. The valuable feedback collected from participants will guide ongoing app refinement, making it a more effective tool for both patients and professionals in the field of TBI rehabilitation.
69 Applying Behavior Analysis to the Interdisciplinary Inpatient Brain Injury Team
Arielle Reindeau1
1Craig Hospital, Englewood, United States
Behavioral disturbances are some of the most pervasive and persistent phenomena that follow an acquired brain injury (Corrigan, 1985). Rehabilitation sites across the United States struggle to provide services for individuals who consistently engage in challenging behaviors (Ketzmer et. al, 2022). At Craig Hospital, in Englewood, Colorado, Physicians and Board Certified Behavior Analysts (BCBA) are integrating the science of Applied Behavior Analysis (ABA) into the acute inpatient setting. This science, based on human behavior, is reshaping and redefining how clinical staff in this early phase of recovery gain information about patient behaviors, communicate about behavioral needs, and utilize their environments to shape socially appropriate behaviors.
The interdisciplinary teams, in conjunction with the newly added BCBA positions, have created novel systems to collect individualized data around behaviors that most impact the current rehab process. Day-to-day data is facilitated by nursing staff and used by the entire interdisciplinary team to help inform decisions. Data is operationally defined using tools validated through the ABA community. Rehab teams focus on the ability to define behavior prior to trying to measure it for best results. The current site utilizes a 15-minute partial-interval time-sampling template with up to 4 operationally defined behaviors. These individualized systems are used in tandem with reliable and validated assessments such as the Agitated Behavior Scale (ABS) (Corrigan, 1985).
Communication for behavioral needs and escalated events have been a primary focus of this program. Staff have received education, feedback and debriefs for all information provided through our quality improvement system. Most importantly, physicians and BCBAs have focused heavily on creating a language around behavior that allows staff to communicate in a way that is intentional and functional. Staff have been encouraged and engaged with the opportunities to improve the way behavior management flows.
Globally, the focus has been on indicating how the environment shapes patient behavior. Utilizing the building blocks we all know - consistency and structure - ABA fills a crucial gap in rehabilitation implementation that exists within the current structure. Although many team members with insight into behavior do exist, behavior analysts uniquely carry skills that allow them to both intervene and educate on behavioral principles across activities of the day. Our talk will include the process used to determine the effectiveness of medications utilized for behavior management. We will describe how staff are able to also use daily information to determine location, interaction structure and reinforcement for patients. The purpose of the current oral presentation will be to provide clinicians with an overview of the science that they can use in any setting to better manage behavior.
70 NASHIA’s Collaborative on Children’s Brain Injury: Working to Improve National Educational Support for Children With Brain Injury
Jennifer Lundine1; Brenda Eagan-Johnson2; Melissa McCart3
1The Ohio State University, Columbus, United States, 2BrainSTEPS Brain Injury Consulting Program, Pittsburgh, USA, 3Center on Brain Injury Research and Training, University of Oregon, Eugene, USA
In 2022, the National Association of State Head Injury Administrators (NASHIA) launched its first special interest group, NASHIA’s Collaborative on Children’s Brain Injury (NCCBI). NCCBI’s mission is to improve services and support for children with acquired brain injury. In 2014, NCCBI was formed outside of NASHIA, and in 2023, partnered with NASHIA to expand the group’s impact. NCCBI’s goals include 1) Identifying and addressing critical gaps in the continuum of services and supports, 2) Collaborating with national key partner groups to establish common language, practices, and to make policy/research recommendations, and 3) Educating, sharing information, developing tools, and resources on supports and services. NCCBI has two active working groups. The Standards of Practice workgroup is reviewing documents used across the United States to assess student history of brain injury. The Educational Policy workgroup focuses on early childhood brain injury and examining the processes to qualify for early intervention by state. The NCCBI workgroup’s findings will inform future projects to address the under-identification of children and adolescents who experience brain injury.
The three co-chairs of NCCBI, and colleagues representing school counseling and school psychology, recently submitted a commentary on eligibility determination for school-age children with traumatic brain injury (TBI). This paper explains the public-school evaluation process, including assessment considerations specific to students with TBI. A significant obstacle contributing to the under-identification of students with TBI is that many school districts require a medical statement for a TBI special education eligibility. To remedy this barrier, the authors propose using a guided credible history interview (GCHI) as an alternative to a medical statement. A GCHI is conducted by a school professional who is familiar with a TBI’s physical, cognitive, emotional, and behavioral effects and symptoms can emerge over time. The person interviewed is someone with knowledge of the TBI event, such as a parent or guardian. The information provided in the GCHI can then be used by schools instead of a medical statement, increasing the likelihood of identification of students with TBI. In 2020, the state legislature in Oregon adopted the GCHI process. First-year implementation data indicates that the number of students identified under Oregon’s TBI special education category increased 21%.
Future research is needed to evaluate the effectiveness of the GCHI to expand the identification of students with TBI so that they receive appropriate learning and behavior support. Students with TBI have nuanced needs that cannot be identified through clinical testing alone. NCCBI will identify and support educational policies that promote expanded use and interpretation of curriculum-based assessments and school-day observation to ensure that investigation of a student’s functional skills occurs where they are likely to show actual deficits.
72 School Transition After Traumatic Brain Injury (STATBI) – Caregiver Perspectives on Services for Students
Jennifer Lundine1; Angela Ciccia2; Erika Hagen1; Nicole Viola1
1The Ohio State University, Columbus, United States; 2Case Western Reserve University, Cleveland, USA
Traumatic brain injury (TBI) is considered a leading cause of acquired disability for children in the US. Despite the high incidence of negative long-term academic, social, and health outcomes for children with TBI, few receive appropriate educational supports. Return to school (RTS) programs have been developed to better assist children with TBI as they return to the classroom. These programs vary widely by state, and no existing RTS program has been systematically evaluated to determine its impact on outcomes for students with TBI. The objective of the School Transition After Traumatic Brain Injury (STATBI) project is to rigorously evaluate the impact of BrainSTEPS, a formal return-to-school (RTS) program, on academic, social, and health outcomes for students in grades K-12 who have experienced TBI of any severity, compared to students who have no formal RTS programming (control arm). STATBI uses a mixed method, cohort-controlled research design. The protocol includes electronic survey administration and virtual interviews with parents and children. This presentation will include data from nine focus groups completed with caregivers from the experimental and control groups during summer and fall 2023. Twenty-five caregivers (100% female) participated in focus groups, with four groups from the control arm and five groups from the experimental arm. The sample included students with mild, moderate, and severe TBI. Questions and discussion focused on how caregivers accessed services, facilitators and barriers to finding care, and their satisfaction with services their child received following TBI. Preliminary analysis of focus group transcripts reveals persistent challenges that caregivers face attempting to find and access necessary supports for mental health and school services for their children with TBI. Caregivers receiving formal RTS support through BrainSTEPS discussed the relief and support provided to them by school-related programming. Caregivers in the control arm discussed persistent difficulties in identifying providers and accessing supports for their children. When supports were identified and provided, unsurprisingly, caregivers were more satisfied with overall service provision. Focus group data is being analyzed further for themes associated with injury severity and time post injury. The STATBI project is unique in its focus on RTS for youth with TBI, and this presentation will describe caregiver perspectives of access to and satisfaction with services for school-age youth with TBI who participate in either formal or non-formal RTS program. Additionally, the sample includes many students who reported having mild injuries but who continued to have academic needs past the typical recovery period that warranted ongoing support services. These findings have important implications for assessing students with TBI as they progress through school. This talk will highlight ongoing study progress and implications for those studying RTS programs for students with TBI.
73 Multidisciplinary Rehabilitation for ABI Patients With Movement Disorders
Fernanda Lapietra de Carvalho2; Karen Madden2; Fran Richardson2; Gemma Bailley2; Esther McEvoy2; Ivana Jankovic2; Sarah Luxon2; Sandra Sanmartin2; Jesse Tulipano2; Tara Dingman2; Zhihui(Joy) Deng1,2
1Mcmaster University, Department of Medicine, Hamilton, Canada; 2Regional Rehab Centre, Hamilton Health Sciences, Hamilton, Canada
Movement disorders are commonly seen clinical phenomena in patients who have suffered a moderate to severe acquired brain injury (ABI). While spasticity and ataxia are well known neurological deficits, less common types of movement disorders are encountered in our inpatient rehab program, which is the focus of this study. Early diagnosis and identification of contributing factors is key to reaching favorable functional outcomes for those patients. Here we present 6 types of clinical conditions including: (1) Parkinsonism with the etiology of ABI versus medication adverse effects. Dopamine agonists and anticholinergic agents may be beneficial for the former while discontinuation of culprit medications is important for the latter; (2) Dystonia with a similar etiology and pharmacological management as parkinsonism; (3) Tardive dyskinesia commonly seen as an adverse effect of dopamine antagonists, for which management is more challenging; (4) Tremor mimicking the symptoms of essential tremor (ET) seen after an injury to the cerebellum or brain stem, for which primidone is usually effective while some other antiepileptic drugs may worsen symptoms; (5) Palatal myoclonus seen after an injury involving the dentato-rubro-olivary pathway, for which antiepileptic medications can be trialed to alleviate symptoms; (6) Chronic post-hypoxic myoclonus which may be well managed with antiepileptic agents such as valproic acid, clonazepam and levetiracetam. We are a multidisciplinary team that specializes in adult ABI rehabilitation. Our team is comprised of physician specialists and allied health professionals including but not limited to pharmacists, physiotherapists, occupational therapists, speech-language pathologists and rehab therapists. We also have ready access to consulting specialists to assist in differential diagnosis and management planning if needed. In addition to medications, non-pharmacological interventions are essential to successfully enhance the function of ABI patients with movement disorders. Allied health teams can assist with positioning, developing strategies and utilizing assistive devices for more controlled movement, and thus creating opportunities to practice. The impact of the above-mentioned neurological conditions on functional movement patterns is assessed throughout the medication trials as the side effects of various medications can take time to develop. Multidisciplinary rehabilitation requires close collaboration among all team members to determine appropriate and effective strategies that, when implemented together, will optimize physical, communication, swallowing, and cognitive function. Continuous collaboration between allied health team members and the medical team is imperative to determine appropriate and effective pharmacological interventions (i.e. to address/manage tremor, hypertonia, movement initiation, etc.) that, in combination with evidence based therapeutic interventions, will enhance and maximize recovery for each patient experiencing movement disorders secondary to ABI.
74 The Back2Play App: A Concussion Management Platform for Children and Youth to Bridge the Gap Between Research and Practice
Joe Steinman1,2; Kristele Pan1,2; Kathy Stazyk1,3; Samantha Perrotta1,3; Maliah Leblanc1; Richard Zhang1; Vereena Andrawes1; Carol DeMatteo1,3
1CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Canada; 2Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada; 3School of Rehabilitation Science, Faculty of Health Sciences, McMaster University, Hamilton, Canada
Background
Traumatic brain injury (TBI) is the leading cause of death and disability for the pediatric population worldwide. With concussions comprising the majority of these TBIs, concussions among children and youth are an established public health concern. However, the management of pediatric concussions, particularly the decision to return to school and activity following concussion, is often inconsistent and a one-size-fits-all approach. To (1) individualize concussion management to each patient’s unique recovery, (2) provide guidance and monitoring for optimal rehabilitation, and (3) revolutionize concussion management in the digital age, the Back2Play App was developed based on CanChild’s evidence-based management strategies and the expertise of pediatric, psychology, and rehabilitation clinicians, machine learning engineers, and exercise science specialists. The purpose of this randomized controlled trial was to evaluate whether the App supports safe and symptom-free return to school and activity.
Methods
Eligible children and youth aged 10-18 were randomized into an App Group and Usual Care Group. Usual Care Group participants completed a symptom survey once daily, and received typical care which usually includes generic guidelines provided by their physicians. App Group participants received an Apple watch with the Back2Play App that provided interactive feedback and monitored real-time biological variables including heart rate and movement; completed a symptom survey thrice daily; and followed CanChild’s evidence-based management strategies. All participants completed two follow-up interviews to assess recovery progress and ascertain if re-injury occurred.
Results
Preliminary results indicate that at follow-up, 78.7% (37/47) of App Group participants had returned to sports, compared to 59.6% (28/47) of Usual Care Group participants (p = 0.074). At the early stages of the Return to School protocol (RTS Stage 1), the mean self-assessed cognitive scale score that measures cognitive activity was greater in the App Group than in the Usual Care Group (2.70 +/- 0.27 [N=53] vs. 2.01 +/- 0.21 [N=45], p < 0.01; error = 95% CI).
Discussion
Recruitment for Phase 3 of this study is nearing completion, with 130 participants of the 160 targeted already recruited. Although not statistically significant, the number of participants having returned to sports at follow-up was greater in the App Group than in the Usual Care Group, potentially indicating a higher likelihood of returning to normal activities. The mean cognitive scale score was also higher in the App Group compared to the Usual Care Group at the earliest RTS stage, suggesting higher cognitive activity at the early stages of recovery in line with CanChild’s management strategies.
Conclusion
Results from this study can inform clinicians of the efficacy of app-based interventions within this population and address the dearth of consistency and personalization in concussion management, ultimately enabling children and youth who have experienced a concussion to return to school and activity safer and sooner.
75 Exploring Hypoxic and Ischemic Brain Injury: Observational Insights and Treatment Approaches in Indian Children With Cerebral Palsy
Priya Kapoor1; Sakshi Pal
1Bharati Vidyapeeth(Deemed To Be University) School Of Audiology And Speech Language Pathology, Pune, India
This study examines hypoxic ischemic brain injuries in the context of cerebral palsy (CP) in India. Children with CP commonly experience issues like epilepsy, hearing loss, and feeding difficulties. These feeding problems result from communication barriers, oral-motor dysfunction, and aspiration. Despite various assessment tools for feeding issues, there’s a lack of options in Indian languages. This study focuses on the complexities of hypoxic ischemic brain injuries, particularly within the context of CP. The objectives of the study are to evaluate the impact of hypoxic and ischemic brain injuries on individuals’ neurological and cognitive functions and provide observational insights to enhance the scientific understanding of these injuries.
The research took place in Pune, Maharashtra, employing a cross-sectional design and convenient sampling. Marathi-translated version of the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) was utilized, comprising 35 items. These items allowed parents to assess both their child’s eating behaviors and their own feelings or strategies concerning feeding issues. The translated BPFAS was administered to parents of children diagnosed with CP. Using the Marathi-translated BPFAS, the questionnaire was structured into five categories: ‘Picky Eaters,’ ‘General Toddler Refusal,’ ‘Toddler Refusal—Textured Foods,’ ‘General Older Children Refusal,’ and ‘Stallers.’
A sample was gathered from the School of Audiology and Speech Language Pathology at Bharati Vidyapeeth (deemed to be a university). Out of the initial group of 50 participants, aged between 9 months and 7 years and diagnosed with cerebral palsy (CP), two participants declined to provide consent for the study, and 21 participants were excluded due to not meeting the inclusion criteria. The inclusion criteria required parents to be native Marathi speakers and their children to be aged 9 months to 7 years with CP attributed to hypoxic ischemic encephalopathy; the rest were excluded.
A descriptive analysis calculated standard deviations and means, revealing no significant gender impact on BPFAS scores. Notably, the study identified distinct feeding challenges among children with CP who displayed milder picky eating tendencies, while younger children in the ‘General Toddler Refusal’ category exhibited common issues like whining and food refusal. The ‘Toddler Refusal—Textured Foods’ category emphasized difficulties with specific food textures, underscoring the need for tailored interventions. Additionally, the ‘General Older Children Refusal’ and ‘Stallers’ categories highlighted CP-related behaviors in food choice negotiation and eating habits. This study offers valuable insights into mealtime behavior patterns in children with CP, underscoring the significance of tailored feeding interventions.
In conclusion, this study sheds light on the multifaceted challenges faced by children with CP in India. The prevalence of CP, its associated comorbidities, and the impact on feeding and communication are important considerations. The findings highlight the pressing need for high-quality prevalence studies in India to better understand the CP landscape and its associated issues.
76 Interdisciplinary Management of Mild Traumatic Brain Injury (mTBI): A Model of Care for Persistent Symptoms in a Pediatric Setting
Lindsay Cirincione1,2; Carolyn Caldwell1; Gray Vargas1; Sherri Clark1; William Ide1,2; J. Alfredo Caceres1,2
1Kennedy Krieger Institute/Johns Hopkins School of Medicine, Baltimore, United States; 2Johns Hopkins School of Medicine, Baltimore, 21205
Introduction
Existing literature is clear that multidisciplinary treatment of persistent mTBI (concussion) symptoms is critical in improving patient outcomes. Institutions are often left to their own devices to determine how to provide this type of care in a way that is viable for providers, maximizes interdisciplinary potential, and is most helpful to patients and families. This study illustrates one model of achieving interdisciplinary care for a patient population with complex, varied, and persistent symptoms following remote mTBI. An interdisciplinary care model involving Medicine, Nursing, Neuropsychology, and Pediatric Psychology is presented using a case series to illustrate common symptom presentation, in-clinic assessment methods, and treatment recommendations. Twelve months of preliminary descriptive data is presented in this abstract, with five years of analysis available by date of presentation. Considerations related to equity, diversity, and inclusion within this population will be discussed.
Methods
Retrospective chart review was conducted of patients experiencing persistent symptoms > six months following an mTBI who were evaluated in a pediatric mTBI multidisciplinary clinic. Patients with findings on neuroimaging were excluded. Three cases with persistent symptoms are illustrated. The interdisciplinary care model is presented with an emphasis on each discipline’s role, assessment methods, and treatment recommendations.
Results
Preliminary data extraction of cases over the course of 12 months was reviewed (n = 23). The mean age of patients was 15.8 years (range: 10-21 years). Patients were primarily female (65.2%; sex assigned at birth), White (73.9%), and not Hispanic (65.2%). Mean time since injury was 22.3 months (range 6-72 months). Most common presenting symptoms included mood-related concerns (83%), headaches (78%), and cognitive complaints (65%). The majority of patients (91%) were fully cleared from a mTBI perspective following the interdisciplinary team evaluation. Mental health support was recommended for 96% of patients and 35% were referred to physical therapy. Analysis including a total of five years of data will be reviewed.
Discussion
An interdisciplinary care model provides specialty evaluation and treatment across physical, cognitive, and emotional domains of functioning while decreasing overall medical utilization rates, reducing the potential for conflicting recommendations among providers, and lessening time away from school and work for patients and their families. Most importantly, interdisciplinary management provides a comprehensive treatment plan, making the path to recovery clear and achievable. It also allows for a broader focus on factors predictive of recovery, which may fall outside the scope of a single-discipline visit.
77 Untangling the Everyday-Using the Rehabilitation Treatment Specification System (RTSS) to Uncloak the Rehabilitation Opportunities Inherent Within CONNECT’s Life Redesign Model to See the Possibilities of the Everyday.
Adam Van Sickle1; Deidre Sperry
1Connect Communities, Hamilton, Canada
This presentation or poster will make use of case examples to demonstrate how the Rehabilitation Treatment Specification System (RTSS) provides the means of moving knowledge from rehabilitation literature to the front lines all in an effort to enhance the work being done at CONNECT. We will explore how the RTSS framework has helped build a greater understanding of the many opportunities for rehabilitation that are present at CONNECT.
For 30 years, CONNECT Communities has supported people in redesigning their lives after brain injury and stroke. CONNECT’s Leading Practice Life Redesign Model includes meaningful community participation with an emphasis on social capital within a context of supported risk-taking. CONNECT originated in British Columbia and is now also located in Hamilton Ontario. In partnership with the local hospital system, Hamilton Health Sciences, people living with Acquired Brain Injury (ABI) are supported to engage in everyday activities to support their Life Redesign Plan. This requires close collaboration with professional team members, those who provide direct daily support (Life Redesign Coaches), and most importantly, the individual and their family. Being able to untangle complex everyday activities to allow for outcome measurement and maximized consistency of approach across the organization is a challenge. In 2016, The RTSS was introduced to rehabilitation Science. The RTSS provides a means of better analyzing, documenting, researching, and discussing the many components of any rehabilitation program. At CONNECT, the RTSS is providing the means of untangling the everyday to describe rehabilitation opportunities for individuals with ABI within CONNECT’s Life Redesign Model.
Utilizing the RTSS, the regulated health professional coaches reviewed the existing Life Redesign Goals and Plans that guide the rehabilitation of 10 residents at CONNECT. The process revealed a new way of seeing rehabilitation. When viewed through a different lens, it was possible to better describe Life Redesign at CONNECT, in terms of the aims, targets, and ingredients of the RTSS. In turn, this created opportunities to disseminate knowledge to all involved. Ultimately, the collaboration among professionals, frontline coaches, family, and the individuals we support, has allowed for greater unity and a better understanding of the rehabilitation layered into the everyday.
79 Minding the Early Brain: Perinatal Events and Intrapartum Exposures as Influences on Child Neurodevelopment
Lisa Kurth1
1University of Colorado School of Medicine, Developmental Pediatrics, Fort Collins, United States
Pediatric traumatic brain injury may consider expanding to include perinatal events and exposures involved in complicated childbirth, since research reveals adverse influences for child neurodevelopmental trajectory. Epidemiological studies link specific intrapartum complexities presenting during labor and delivery with rising child neuropsychiatric outcomes, justifying the novel concept of perinatal neurotrauma. These overlapping, interacting factors combined with elevated maternal gestational BMI, confer a disruptive cascade of neural events which may risk lifelong impairments for children. Rising neuropsychiatric conditions including ADHD and Autism have unconfirmed etiologies, yet complicated childbirth associations. Concomitant cognitive dysexecutive symptoms, emotional dysregulation, social and academic issues often persist into adulthood. While research has considered genetic etiology, it is unlikely genetics alone trigger these outcomes. Plausibly, events introduced during most sensitive developmental periods may affect the malleable fetal brain with risky downstream effects, altering child neurodevelopment. Birth complications typically involve well-respected measures aimed at expediting childbirth. One first-line, synthetic uterine simulant effectively assists > 50% of all U.S. childbirths, despite its poorly understood fetal impact. Exponential increases in exogenous uterine stimulation and dosage inconsistencies raise concerns of consequential maternal-fetal transmission. Labor duration and pharmacological dosages are important algorithms to disentangle since these are all modifiable factors. Established repercussions of this early environmental exposure include fetal distress, low Apgar scores, uterine hyperactivity, FHR abnormalities, NICU admissions and ischemia/asphyxia/hypoxia. Putative neuropathophysiological models include fetal intolerance to prolonged dosages, labor impact; epigenetic triggering, oxytocin receptor hyperstimulation and/or receptor oversaturation. Other considerations include neuroinflammation; hypertonic uterine contraction pressure imposing neuropathogenic alterations and diffuse axonal injury. Plausibly, disharmonious compounds, GABA downregulation; blood-brain barrier breach and/or placental permeability may interactively compromise fetal neuroprotective integrity. Additionally, the underexplored neuropathophysiological interpretation of pharmaco*kinetics involving synthetic properties may play a key role in fetal brain impact. Interestingly, maternal BMI/adiposity, a modifiable gestational health factor, increases odds for medically assisted childbirth owing to diminished uterine contractility in obese mothers. The shared effects of maternal BMI with chemically expedited labor, and its two-fold impact on offspring brain development is under-investigated, begging further exploration since its potential future contribution to the study of pediatric traumatic brain injury is imperative. While a signature, underlying, neuropathophysiological mechanism(s) linking childbirth complications and maternal gestational BMI to pediatric brain injury lacks confirmation, mixed evidence associates these factors directly with child neuropsychiatric phenotypes. Logically, the vulnerable fetal brain’s reaction to early, overlapping events and exposures is important to better understand. It is crucial to appreciate that a constellation of perinatal factors may risk future functional and behavioral impairments for children. Early vulnerabilities, potentially linked to in-utero exposures and obstetric dynamics, may destabilize and/or disrupt fetal brain development, warranting aggressive research and inclusion in the burgeoning field of pediatric brain injury as a critical child public health issue.
80 “You Should Be Better By Now!” Clinical Guidelines for Managing Prolonged Symptom Sequelae in TBI
Lisa Kurth1
1University of Colorado School of Medicine, Developmental Pediatrics, Fort Collins, United States
The landscape of prolonged symptomatology and functional impairments following traumatic brain injury (TBI) can become perplexing and enigmatic to unravel etiologically. This constellation of TBI-induced symptoms can present curious, latent emerging symptoms which are difficult to distinguish across clinical settings. Since the specific biomechanics and aerodynamics involved in each injury scenario can vary widely, the combination of variability across individual coping styles, as coupled with personalized immune system responses, can interactively determine lingering and evolutionary injury-induced symptom sequelae. A sizeable amount of these persistent, post-morbid TBI symptom profiles may functionally overlap, and can feature multi-organ-system involvement. As an additional complication, impaired symptom awareness can amplify TBI-induced trauma and PTSD symptomatology for the injured individual, since an association to actual injury dynamics often goes underrecognized, and/or misdiagnosed, subsequently postponing essential treatment(s). When an injured individual discloses or displays curious, continuous and/or newly emerged TBI-related symptoms which are not taken seriously by others, these courageous communications may become misunderstood, dismissed, disbelieved, and underappreciated. Misinterpretation of symptom self-disclosures as being insincere, confabulated, or malingering can be difficult to cope with, especially when originating from family, friends and across other meaningful relationships. These discrediting impressions add baffling layers of burden to an individual suffering with a TBI, complicating the already challenging task of healing and recapturing pre-injury functioning. When the response of others involves questioning the authenticity of prolonged symptoms, this feedback translates atmospheric doubt, conveying non-supportive recovery expectations. This stress provocative dynamic can dilute relationship integrity, induce trauma triggers, reactivate, and amplify residual PTSD, and compound unresolved, post-morbid symptoms for the injured individual. A self-protective avoidance response of social disengagement is common, as the individual withdraws or self-isolates to minimize negative exposure impact. Essential treatment targets should encompass a thorough exploration of pre-morbid vs. post-morbid profiles, based on patient self-report, collateral input, and findings from standardized testing aimed at assessing and quantifying post-morbid functional impairment(s) and pre- vs. post-morbid discrepancies. Referral to well-informed, multidisciplinary providers who rely on evidence-based, specialized ancillary services can assist in discerning symptom persistence and its link to TBI-related events, while expediting multimodal interventions as may be warranted. A two-pronged psychotherapeutic approach should prioritize providing guidance and support in identifying and recognizing unrelenting post-morbid symptom comorbidities featuring neuropathophysiological, multi-system involvement. Secondly, evidence-informed psychoeducation should include didactic, portable coping skills which focus on tracking routine functioning across atmospheres, monitoring sleep architecture, nutrition, integrating modest exercise, budgeting energy output, mood regulation, promoting a self-healing mentality, and bolstering confidence in healing, health resilience and recovery. Restoring a sense of dignity for the TBI-injured individual by validating symptom legitimacy and launching endeavors to clinically investigate symptom etiology via referral(s) and clinical collaboration with multidisciplinary providers are essential approaches in addressing prolonged TBI-induced symptomatology.
82 Neuroprotective Effects After TBI of Enteric Hydrogen Generation From Si-Based Agent in Mice Model
Sanae Hosomi1; Hiroshi Ito1; Yoshihisa Koyama2,3; Yuki Kobayashi4; Hiroshi Ogura1; Hikaru Kobayashi4; Shoichi Shimada2,3; Jun Oda1
1Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan; 2Department of Neuroscience and Cell Biology, Osaka University Graduate School of Medicine, Suita, Japan; 3Addiction Research Unit, Osaka Psychiatric Research Center, Osaka Psychiatric Medical Center, Suita, Japan; 4Institute of Scientific and Industrial Research, Suita, Japan
Background
Traumatic brain injury (TBI) is a condition that can cause oxidative stress, inflammation, and cell death in the brain. Antioxidant therapies have been studied as a potential treatment for TBI, including hydrogen treatment. Si-based agent continues generating hydrogen for more than 24 hours by the reaction with water and generates approximately 400 mL of hydrogen. However, there is no specific information available on the effectiveness of Si-based agents for TBI. This study aimed to investigate the beneficial effects of the Si-based agent for TBI in a mice model. We used the controlled cortical impact model (CCI) mice. The mice were fed a control diet or a diet containing the Si-based agent for one week before CCI. One week after CCI, the Y-maze and open-field tests were performed as behavioral tests. As a result, mice treated with Si-based agents (n=19) showed a notable increase in the spontaneous alternation values compared to the control group (n=19) (control group vs treatment group = 61.7% (51.9-69.2%) vs 74.2% (60.3-85.7%): p=0.03). However, there were no significant differences between the control group and treatment group in the open-field test (time in the inside zone; control group vs treatment group = 27.2 seconds (22.6-34.5 seconds) vs 30.1 seconds (16.8-34.2 seconds): p=0.99, total distance; control group vs treatment group = 29.1 meters (22.5-34.3 meters) vs 28.8 meters (23.1-35.8 meters)). These findings indicate that the Si-based agent is found to prevent impairment of spatial learning and memory after CCI, which should be considered as a novel hydrogen administration method for TBI.
83 Correlation of Computerized Posturography and Saccadic Latency in the Rehabilitation of Postural Abnormalities
Victor Pedro1; Richard Lyon1; Diane Bienek1
1International Institute for the Brain, New York, United States
Introduction
Research into the dysfunction of the postural control system in humans has been inconclusive as to the rehabilitative role of the oculomotor subsystem. Studies on the relationship between pursuit and saccadic activities in the rehabilitation of postural abnormalities have had conflicting findings regarding the predictable role of oculomotor activities in rehabilitation. Most studies are performed on healthy athletes rather than challenging compromised patients in a clinical setting. The aim of this study was to measure computerized posturography and saccadic latency of a subject population with loss of postural control to include migraine headaches (39.3%), post-concussion syndrome/traumatic brain injury (35.7%), vertigo (17.9%), and other brain disorders (7.1%) as primary diagnoses.
Methods
A matched pairs design (pre- and post-treatment assessments) was used to assess the efficacy of a course of personalized Cortical Integrative Therapy, as the rehabilitative strategy. Postural control of 28 refractory adult patients, aged 18 to 64, was measured by computerized posturography and saccadic latency by videonystagmography. As head movements challenge the subject by generating a vestibular stimulus in addition to that generated by the subject’s sway, computerized posturography was conducted with the head in neutral position, right and left. Posturography scores in the three testing positions were compared to right and left horizontally directed saccades latency. These measurements were taken over the intervention course (mean = 7.66 weeks, range 0.57 to 20.29 weeks).
Results
Efficacy of the personalized Cortical Integrative Therapy was indicated by a near 25% (P < 0.05) improvement in the posturography value. Post-intervention, the average latency values with the head in the neutral position and the head in left rotation demonstrated a negative linear correlation (P ≤ 0.05) in both directions of saccadic activity. In contrast, right head rotation testing yielded no statistically significant correlation between latency and posturography values. As expected, no correlation was observed between the postural stability and oculomotor function at baseline pretreatment testing.
Conclusion
The relationship between saccadic activities in the rehabilitation of postural abnormalities was demonstrated in a heterogeneous subject population with varied brain injuries and brain-based disorders. Moreover, computerized posturography data suggests that head rotation can help direct therapeutic strategy. Altogether these data suggest a rehabilitative role of vestibular postural systems in conjunction with oculomotor systems, which beckons development and implementation of new intervention approaches for broad-based clinical practice.
84 Advancing Traumatic Brain Injury Treatment: The Potential of Photobiomodulation, Its Mechanisms and Clinical Evidence
Lew Lim1
1Vielight, Inc., Toronto, Canada
Objective
This abstract investigates the utility of Photobiomodulation (PBM) for Traumatic Brain Injury (TBI) treatment, aiming to expand therapeutic options beyond symptom management. It presents a synthesis of PBM’s biological mechanisms, a compilation of clinical evidence, and an overview of its regulatory considerations.
Methods and Mechanisms
PBM introduces red and near-infrared (NIR) light to targeted tissues, instigating a cascade of mitochondrial and cellular responses conducive to brain healing. This review elucidates PBM’s action in modulating the mitochondrial electron transport chain, fostering gene transcription, and stimulating growth factor production. The activity also attenuates the excitotoxicity and inflammation which are characteristic of TBI.
Clinical Evidence
Emphasizing clinical outcomes, substantial evidence from recent studies is presented, demonstrating PBM’s effectiveness in improving cognitive and behavioral symptoms associated with TBI. Specific improvements in depression, sleep quality, cognitive function, and PTSD symptoms have been consistently reported. Notably, reaction time and grip strength enhancements serve as additional objective metrics of PBM’s impact on neural recovery. Additionally, case reports involving former athletes with suspected chronic traumatic encephalopathy (CTE) reveal symptom alleviation in similar domains, reinforcing PBM’s therapeutic potential even in a worrying spectrum of brain injuries. The parallels drawn between PBM’s effects on CTE and clinical evidence for Alzheimer’s disease underlines a broader application for neurodegenerative disorders.
Personalization Through Technology
Recognizing the heterogeneity of TBI, this presentation advocates for the use of artificial intelligence (AI) to personalize PBM treatment. By analyzing individual brain activity through EEG and fMRI, AI algorithms can optimize PBM settings, tailoring the therapeutic regimen to patient-specific neurophysiological profiles.
Pivotal Trial and Regulatory Progress
Looking forward, the presentation details the design of an upcoming multi-site randomized controlled trial (RCT) encompassing 280 subjects to substantiate PBM’s efficacy for chronic TBI symptoms. This RCT is a critical step toward obtaining FDA clearance, a milestone that would validate PBM as a sanctioned therapy for TBI.
Conclusion
PBM is posited as an innovative, non-invasive treatment modality for TBI, distinguished by its ease of use and potential for integration into home settings. The convergence of promising clinical evidence and ongoing research underscores the need for continued exploration into PBM’s capabilities. With AI’s advent, the personalization of treatment parameters is anticipated to further enhance PBM’s clinical applicability and outcomes in TBI recovery.
87 De Novo Rehabilitation Recommendations for American College of Surgeons Traumatic Brain Injury Best Practice Guidelines 2024
Brooke Murtaugh1; Joseph Giacino2; Alan Weintraub3; Flora Hammond4; Geoffrey Manley5
1Madonna Rehabilitation Hospitals, Lincoln, United States; 2Harvard University, Boston, United States; 3Paradigm Corporation, Littleton, United States; 4Indiana University School of Medicine, Indianapolis, United States; 5University of California San Francisco, San Francisco, United States
In 2015, the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) published Best Practices in the Management of Traumatic Brain Injury which provided practice and care recommendations for patients with Traumatic Brain Injury (TBI) served by trauma centers. The purpose of the TBI Best Practice Guidelines (BPG) is to provide ACS verified trauma centers evidence and expert-based recommendations to determine best practices and quality care for TBI to support optimal long-term outcomes and recovery. These 2015 BPGs were developed by a committee consisting of neurotrauma, neurosurgery, neurocritical care and nursing experts and were endorsed by ACS and TQIP.
Since 2015, TBI research, published evidence and clinical care has evolved in multiple domains warranting a re-evaluation of the current TBI BPGs. ACS and TQIP supported an update to the 2015 publication to be congruent with current evidence and recommendations. The revised TBI Best Practice Guidelines builds on the work of the first edition from 2015. The updated 2024 TBI Best Practice Guidelines includes De Novo sections of TBI trauma care that were not included in the previous edition. Recently, ACS has been deliberate in pursuing collaboration with rehabilitation experts as the benefit of early rehabilitation improves outcomes from trauma and TBI patients and lead to the genesis of a focused rehabilitation best practice recommendation section within the new 2024 TBI BPGs as a de Novo section.
A cadre of TBI and rehabilitation experts were assembled to participate in the ACS TBI BPG committee to develop novel rehabilitation recommendations for trauma centers. Rehabilitation experts conducted in-depth review of rehabilitation literature to guide development of robust rehabilitation recommendations that would promote early initiation of rehabilitation within the ICU setting, emphasize the benefits of early rehabilitation for all severities of TBI and support the integration of rehabilitation experts into the core trauma team.
This poster will disseminate the final “key points” that summarize the evidence and expert consensus for rehabilitation best practice after TBI for trauma centers. These key points will be included in the final publication and will be available as open access in January 2024. The six finalized recommendations address rehabilitation for the spectrum of TBI severity and emphasize the importance of rehabilitation specialists as core members of the trauma team.
88 Investigating Longitudinal Cognitive Outcomes and Mental Health in Moderate-Severe TBI
Marina Everest1; Jeremy Brand1; Loretta Norton1
1Kings University College at Western University, London, Canada
Introduction
Brain injury is the leading cause of death and disability for Canadians under the age of 40 and approximately 1.5 million Canadians live with the effects of an acquired brain injury. Cognitive impairment is a common sequelae of a traumatic brain injury (TBI). One limitation of current research in understanding cognitive deficits is that the focus has been predominantly on cross-sectional data, which does not detect the natural progression of cognitive recovery. Thus, the objective of the current study is to use a longitudinal approach using a web-based neurocognitive assessment tool to document the natural course of cognitive recovery in adults with moderate-to-severe TBI. Additionally, one factor to consider in predicting long-term outcomes after TBI is the presentation of mood disturbances. As such, this study also aims to longitudinally examine the relationship between cognitive impairment after TBI and the possible mediating effect of mood difficulties during recovery.
Methods
We recruited 34 patient participants (12 TBI, 22 traumatic body-only injury) through the London Health Sciences Trauma Program’s Outpatient Clinic in London, Ontario and 34 age and sex-matched healthy control participants. Participants were English-speaking, between 18-65 years old (M=41.10, SD=14.62), with no prior history of neurological or cognitive impairments. Brain injury participants were considered to have severe-moderate traumatic brain injury as defined by the Mayo TBI Severity Classification System and traumatic body-only injury patients required admission to hospital for traumatic injury that did not involve a brain injury. Both groups were assessed at three time points: 2 weeks post-hospital discharge, three months, and six months. At each time point, participants completed seven online neurocognitive tests and reported their levels of anxiety, depression, and quality of life.
Results
Both TBI and traumatic injury to body groups had significant impairment in their verbal ability compared to healthy controls and no improvements were observed over the 6-month period. TBI patients performed worse than the traumatic body-injured group on cognitive measures of reasoning but not short-term memory. TBI and traumatic body-injured patients did not differ significantly with respect to anxiety or depression. However, TBI patients reported a significantly lower quality of life than the non-brain-injured group.
Discussion
Significant domain-specific cognitive impairments were found in TBI patients even when compared to those with traumatic body injuries. The findings highlight the value of a longitudinal assessment that can be self-administered remotely by patients to allow for a clearer understanding of the natural course of cognitive recovery.
90 Screening for Cognitive Impairment Post-Concussion in a Non-Athlete Population – Findings From the Toronto Concussion Study
Evan Foster1; Paul Comper1,2; Tharshini Chandra1; Lesley Ruttan1; Laura Langer1; Aaryan Adnan1; Elizabeth L Inness1,2,3; George Mochizuki1,2,4; Catherine Wiseman-Hakes1; Mark Bayley1,2
1Toronto Rehab Institute - UHN, Toronto, Canada; 2Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada; 3Department of Physical Therapy, University of Toronto, Toronto, Canada; 4School of Kinesiology and Health Science, York University, Toronto, Canada
Measuring cognitive difficulties post-concussion is challenging. ‘Baseline’ testing paradigms have individuals complete neurocognitive tests before a concussion occurs (e.g., pre-season for an athlete), followed by post-injury testing for comparative purposes. Evidence suggests that this is effective but is not always feasible. The second, ostensibly more common method, is to compare an individual’s post-concussion neurocognitive test scores to published norms. The purpose of this project was to examine the utility of neurocognitive testing to screen for cognitive impairment following concussion in a general adult population, using two study designs. Study 1 involved 343 adults (17-85 years of age) seen within seven days of concussion. Subjective cognitive difficulties were characterized by the Sport Concussion Assessment Tool (SCAT) scores for the four cognitive items. Objective neurocognitive measures included Trails A & B and Symbol Search & Coding (administered at Weeks 1, 2, and 12 post-injury), and a measure of verbal learning and recall and Digit Span (Weeks 2 and 12). Scores placing at or below the 3rd percentile on any measure were classified as ‘impaired’. 174 (50.7%) participants reported ‘mild’ cognitive SCAT symptoms; 124 (36.2%) as ‘moderate’; 45 (13.1%) as ‘severe’. Between 1-26 participants (0.3-7.6%) were classified as ‘impaired’, depending on the neurocognitive measure used. Those with severe subjective cognitive difficulties had lower neurocognitive test scores compared to the other groups, however they were still within the ‘average’ range using normative data. Determining an objective indicator of cognitive impairment related to subjective difficulties using a norms-based approach was not established. Study 2 employed a case-control design using 30 adults with acute concussion and 30, non-concussed control participants. A preliminary analysis of 29 non-concussed controls (median age: 24 [IQR 23-28] years, 20 females (67%), average years of education: 16.4 [SD: 1.4]) and 12 age, sex, and education-matched individuals with concussion (median age: 26 [IQR 24-30] years, 11 (92%) females, average years of education: 16.0 [SD: 2.8]), completed the same neurocognitive measures at Weeks 1, 2, and 8 post-injury. Preliminary analyses showed there were few measures with significant differences between cohorts at any single assessment (Coding Week 1, p=0.047; Delayed Recall Week 8, p=0.028). However, the non-concussed cohort improved significantly on several tests over time where the concussed cohort did not (i.e., Learning Week 1 to 8, non-concussed p=0.002, concussed p=0.134), suggesting an absence of learning effect in the concussed cohort. Full dataset to be presented at the conference. Without a baseline approach, using test norms to qualify and quantify a person’s subjective cognitive symptoms may yield false negative results. Therefore, more specific normative data (i.e., adjusting for learning effects) is needed to accurately evaluate cognitive performance post-concussion. Without this, the clinical focus shouldbe to provide treatment and education for any specific self-reported symptoms.
91 Social Determinants of Health and Lifetime History of Concussion in School-Aged Children and Adolescents in the United States
Grant Iverson1,2,3,4; Julia Maietta1,2,3; Nathan Cook1,2,3
1Massachusetts General Hospital, Cambridge, United States; 2Harvard Medical School, Boston, USA; 3Spaulding Rehabilitation Hospital, Charlestown, USA; 4Schoen Adams Research Institute at Spaulding Rehabilitation, Charlestown, USA
Introduction
Social determinants of health (SDoH) include socioeconomic and environmental factors that can influence health outcomes. SDoH are understudied in the concussion literature. Previous research suggests racial/ethnic and socioeconomic disparities in concussion care access. However, whether SDoH are associated with increased likelihood of sustaining a concussion remains unknown. The current study investigated whether SDoH are associated with parent-reported lifetime history of concussion in children and adolescents in a national sample.
Methods
The 2021 National Survey of Children’s Health is a national survey that collects parents’ self-reported health data on their children. Data from 34,077 youth (ages 5-17) were selected with complete data on the lifetime concussion history survey question. SDoH variables of interest included: primary language spoken at home, family income, parental level of education, and current health insurance. Separate binary logistic regressions were conducted with parent-reported lifetime concussion history as the dependent variable and demographics/SDoH variables as the predictor variables. A multivariable logistic regression was conducted including all predictors in the same model to examine the independence and magnitude of their associations.
Results
In the univariable logistic regressions male sex (OR = 1.4, p < .001), adolescent age (OR = 3.1, p < .001), playing a sport in the past 12 months (OR = 1.9, p < .001), and having current healthcare coverage (OR = 1.5, p < .01) were associated with significantly higher lifetime history of concussion. Hispanic/Latino ethnicity (OR = 0.69, p < .001), non-English primary language (OR = 0.23, p < .001), lower level of parental education (OR = 0.82, p < .001), living in poverty (OR = 0.63, p < .001), and identifying as Black or Asian (OR = 0.55 and 0.31, respectively, p < .001) were associated with significantly lower lifetime history of concussion. In the multivariable model, after accounting for the combined effects of all predictors, significant independent predictors of lower lifetime history of concussion were lower level of parental education (OR = 0.92, p < .05), non-English primary language (OR = 0.36, p < .001), and identifying as Black or Asian (OR = 0.54 and 0.36 respectively, p < .001).
Conclusions
Several demographic and SDoH variables were associated with lower parent-reported lifetime history of concussion in school-aged children and adolescents including younger age, female sex, Black or Asian race, and Hispanic ethnicity. Adjusting for all variables, lower parental education, not speaking English as the primary language at home, and Black or Asian race were independently associated with lower lifetime history of concussion. Lower health literacy or access to care may contribute to families being less likely to recognize symptoms of concussion or seek out medical care for such an injury.
92 Lifetime History of Concussion Among Children and Adolescents With ADHD: Examining Differences Based on Age, Medication Status, and Parent-Reported ADHD Severity
Julia Maietta1,2,3; Grant Iverson1,2,3,4; Nathan Cook1,2,3
1Massachusetts General Hospital, Cambridge, United States; 2Harvard Medical School, Boston, USA; 3Spaulding Rehabilitation Hospital, Charlestown, USA; 4Schoen Adams Research Institute at Spaulding Rehabilitation, Charlestown, USA
Introduction
Previous research has suggested greater lifetime concussion history among children/adolescents with attention-deficit/hyperactivity disorder (ADHD) compared to peers without ADHD. This research has focused on youth athlete’s self-reported ADHD history, as opposed to parent-reported diagnoses, and those studies have not examined differences across broad age spans. It is unclear if ADHD severity or medication status are associated with greater lifetime history of concussion. The current study investigated the association between parent-reported ADHD, ADHD severity, and medication status with lifetime concussion history in a national sample. We hypothesized that parent-reported ADHD severity would be associated with greater parent-reported lifetime concussion history, and that this would not differ across age ranges. We also hypothesized that, among youth with ADHD, those who were taking ADHD medication and those with mild (vs. moderate/severe) ADHD would have lower lifetime concussion history.
Methods
A sample of 33,914 children/adolescents (ages 5-17, mean = 11 years, SD = 4; 47.9% female) were selected from the 2021 National Survey of Children’s Health (those with complete data on the variables of interest). Overall, 6.2% of youth had parent-reported history of concussion (n = 2,103) and 13.4% had a history of parent-reported ADHD (n = 4,560). ADHD severity (mild or moderate/severe) and medication status (yes/no) were parent-reported for those children/adolescents who had current ADHD. A Mantel-Haenszel analysis was used to assess the associations between ADHD and lifetime concussion history across 5 age groups (5-7, 8-10, 11-13, 14-15, and 16–17-year-olds). Additional Mantel-Haenszel analyses were used to assess the associations between lifetime history of concussion and ADHD severity as well as medication status across the different age groups.
Results
Youth with ADHD were more likely to have greater parent-reported history of concussion across all 5 age bands (χ2Mantel-Haenszel = 80.97, p < .001). However, odds ratios (OR) differed across age-groups (χ2Breslow-Day = 18.48, p = .001). The greatest difference was found in the 5-7-year-old age band (OR = 3.05) and ORs for older ages were smaller (8-10 OR = 1.68; 11-13 OR = 2.04; 14-15 OR = 1.62; 16-17 OR = 1.30). There were no differences in lifetime concussion history for those with mild ADHD versus moderate/severe ADHD (χ2Mantel-Haenszel = 0.02, p = .90). Similarly, there were no differences in lifetime concussion history for those taking ADHD medication versus those who were not taking medication (χ2Mantel-Haenszel = 0.78, p = .38).
Conclusions
Consistent with previous literature, youth with ADHD had greater lifetime concussion history. Contrary to our hypotheses, this difference was not consistent across ages, as differences between those with and without ADHD were larger for younger children compared to older children and adolescents. Also, among youth with ADHD, parent-reported ADHD severity and medication status were not associated with lifetime concussion history.
93 Patient, Caregiver, and Physician Perspectives of Acute Concussion Care and Management
Evan Foster1; Monica Szczypinski1; Tharshini Chandra1; Paul Comper1,2; Mark Bayley1,2,3
1Toronto Rehab Institute, University Health Network, Toronto, Canada; 2Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada; 3Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Canada
Concussion is a significant public health concern due to the underestimated frequency of the injury and in some cases, the potential for prolonged disability. In recent years, there has been a shift to participatory-action research models in health research whereby individuals with the disease or injury of interest are directly involved in the research itself. Employing a participatory-action research model on a local level can provide important feedback and guidance to research teams to help shape future research and care. This project employs a participatory-action research model to understand patient, caregiver, and physician experiences, and to determine stakeholder-informed research objectives that can be investigated in an acute concussion clinic. This study uses a modified Delphi approach. Semi-structured interviews have been conducted with individuals with concussion (or who have recently recovered from their concussion), their caregivers/family, and clinic physicians. All participants were 18 years of age or older and recruited from an acute concussion clinic in Toronto, Canada. Interviews were audio-recorded and transcribed, and transcripts were analyzed qualitatively and sorted into themes. To ensure that the patient perspective is continuously kept at the forefront of this work, an advisory committee of past patients has been recruited to help inform the: 1) research study design; 2) interview questions; 3) interpretation of the results; and 4) ways in which results should be disseminated. 11 participants have completed a semi-structured interview to date (n=5 individuals with concussion, n=3 caregivers, n=3 clinic physicians). An additional 9 participants will be recruited, and full results will be shared at the conference. After an interim qualitative analysis of the interview transcripts, the following themes were defined (in consultation with the advisory committee): concussion symptoms (i.e., direct experience with headache, cognitive difficulties), subjective experience with symptoms (i.e., being overwhelmed by concussion symptoms, frustration with fluctuating symptoms), caregiver experience (i.e., feelings of helplessness, providing household support), facilitators of recovery (i.e., normalizing recovery experience, value of early intervention), return to activities (i.e., modified work duties, supportive work environment), and challenges with providing/receiving care (i.e., financial burden of treatment, compliance with recommendations). These interviews have provided unique perspectives on the barriers, facilitators, and experiences of individuals with concussion, their caregivers/families, and clinic physicians in the context of an acute concussion clinic. The next steps consist of collaborating with the advisory committee to interpret interview themes into research objectives which will be ranked by a second group of participants to create stakeholder-informed research priorities that can be investigated in the future.
94 Aerobic Exercise Post-concussion: Can Findings Be Translated Into a Non-Athlete, Adult Population? Results From a Pilot Study
Evan Foster1; Laura Langer1; Mark Bayley1,2,3; Paul Comper1,3; Tharshini Chandra1; Aidan Snaiderman1,4; Ainsley Kempenaar1,2; Elizabeth L Inness1,3; Cynthia Danells1; David Lawrence1
1Toronto Rehabilitation Institute, University Health Network, Toronto, Canada; 2Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Canada; 3Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada; 4University of Guelph, Guelph, Canada
Background
A growing body of literature has demonstrated that aerobic exercise (AE) can be beneficial in improving outcomes from concussion. This evidence resulted in an update to recent consensus guidelines for the treatment of sport-related concussion, which recommend initiating light AE within two days of injury. Most research has focused on athletes recovering from sport-related concussion. Less is known about the principles of AE following non-sport-related concussion. The goal of this pilot study was to examine the efficacy of various methods to inform AE recommendations post-concussion in a general adult population.
Methods
This pilot study represents a subset of the Toronto Concussion Study population. Participants were eligible for pilot study inclusion if they were 18-45 years of age and at low risk for underlying cardiac disease (determined by the treating physician). Participants who were either uninterested or ineligible were followed regularly by the clinic physician (“Usual Care” cohort). Eligible participants were randomly assigned to either the “Exercise Testing (ET) plus Usual Care” cohort, or the “Exercise Testing (ET) plus Individualized Prescription” cohort. All randomized participants completed a Buffalo Concussion Treadmill Test (BCTT) within seven days of injury. The “ET plus Usual Care” cohort received usual care AE recommendations, while the “ET plus Individualized Prescription” cohort received an individualized prescription based on their BCTT performance. Participants enrolled in both “ET” cohorts were provided with a heart rate (HR) monitor to wear during all waking hours, until they were deemed to be recovered from their concussion by a clinic physician. Kaplan-Meier survival analyses were conducted to evaluate for differences in time to recovery between each of the study cohorts. Log rank tests were used to compare the survival curves for all analyses.
Results
75 participants were included in this analysis (average age: 31.2 years [SD 11.4], 65.7% female). 20 participants were eligible and randomized to either the “ET plus Usual Care” cohort, or the “ET plus Individualized Prescription” cohort (10 per arm). There was an observed longer time (restricted mean survival time [RMST]) to recovery of the “Usual Care” cohort (n=55, 7.2 weeks) compared to the combined “ET” cohorts (n=20, 5.7 weeks, p=0.046). However, there was no significant difference in time to recovery between the “ET plus Usual Care” cohort (n=10, 6.2 weeks) and the “ET plus Individualized Prescription” cohort (n=10, 5.0 weeks, p=0.350). There was no significant difference in minutes spent above certain HR thresholds (50-90% of age-predicted max HR) between the two “ET” cohorts (p=0.295-0.968).
Conclusion
Normalization of AE early post-concussion, under supervision, appears to improve recovery time post-concussion. Individualized AE prescription did not improve outcomes, nor did it alter activity levels in our sample. Future rigorous studies should further examine the role of supervised AE in the acute phase post-concussion.
95 What Do You Do When There Are Gaps in Peer-Reviewed Evidence? Insights From the Canadian Guideline for Rehabilitation of Adults With Moderate to Severe Traumatic Brain Injury
Eleni Patsakos1; Judith Gargaro1; Olga Yaroslavtseva1; Aishwarya Nair1,2; Mark Bayley1,2
1University Health Network, Toronto, Canada; 2University of Toronto, Toronto, Canada
Background
The quality and quantity of evidence varies widely across different aspects of Moderate to Severe Traumatic Brain Injury (MSTBI) Rehabilitation research. There is a notable lack of published research evidence to inform evidence-based recommendations. This is especially prominent in the new and emerging areas of rehabilitation, such as Telehealth and Intimacy and Sexuality. The Canadian Clinical Practice Guideline for the Rehabilitation of Adults with Moderate to Severe Traumatic Brain Injury addresses this gap following a robust living update process that consists of ongoing identification of research literature, expert panel review, rigorous evaluation of evidence quality and achieving clinical consensus in consultation with persons with lived experience (PWLE) to develop and modify current evidence-based recommendations in the areas that lack published research.
Methods
A rigorous multi-component guideline review process was developed and refined to ensure that recommendations reflect the rapidly emerging evidence and address the priorities identified by end users and people with lived experience.
1) Systematic review of published MSTBI evidence
2) Priorities identified by PWLE of MSTBI and guideline end users through surveys and focus groups
3) Diverse interdisciplinary expert panels that include PWLE
4) Online and offline review of the current published evidence, clinical and lived experience
5) Rigorous grading of available evidence
6) Expert panel voting to achieve a minimum of 75% by 80% of the expert panel
Results
Since 2015, this review process has yielded 351 recommendations divided into 21 chapters focusing on different domains of MSTBI rehabilitation. Currently, the Guideline includes 239 Consensus-based recommendations which comprise 68% of the Guideline. Two new sections were added in 2022/23: Telerehabilitation - 14 recommendations including 11 (79%) consensus-based and Intimacy and Sexuality - 10 recommendations including 9 (90%) consensus-based. Recommendations were added that responded to PWLE comments that the guideline did not stress the importance of continuing rehabilitation into the community through participation in daily activities and promoting hope for ongoing improvements. Focus has also been on developing algorithms and tools to facilitate implementation.
Conclusions
This comprehensive TBI rehabilitation guideline uses a transparent and methodologically robust review process that integrates knowledge and experience of diverse interdisciplinary expert panels including the people with lived experience of MSTBI. This process allows the development of high-quality recommendations in the priority areas where published evidence is currently lacking. Including consensus-based recommendations and tools helps ensure that the guideline contains all relevant, current and critically evaluated recommendations that integrate the new areas of rehabilitation and incorporate the needs, values and preferences of PWLE.
96 Relationship Between Extreme Pain Phenotypes and Psychosocial Outcomes in Persons With Chronic Pain Following Traumatic Brain Injury
Jessica Ketchum1; Jeanne Hoffman2; Stephanie Agtarap1; Flora Hammond3; Aaron Martin4,5; William Walker6; Ross Zafonte7; Cynthia Harrison-Felix1; Risa Nakase-Richardson8,9,10
1Craig Hospital, Englewood, United States; 2Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, USA; 3Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine & Rehabilitation Hospital of Indiana, Indianapolis, USA; 4Mental Health and Behavioral Science Service, James A. Haley Veterans Hospital, Tampa, USA; 5Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, USA; 6Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, USA; 7Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, and Harvard Medical School, Boston, USA; 8MHBS/Polytrauma, James A. Haley Veterans Hospital, Tampa, USA; 9Sleep and Pulmonary Division, Department of Internal Medicine, University of South Florida, Tampa, USA; 10Defense Health Agency Traumatic Brain Injury Center of Excellence, Tampa, USA
The objective of this secondary analysis was to examine the relationship between extreme pain phenotypes (based on pain interference and perceived improvement) and psychosocial outcomes among persons with chronic pain after moderate-to-severe traumatic brain injury (TBI). In total, 1762 TBI Model Systems (TBIMS) participants 1 to 30 years postinjury reporting chronic pain were recruited as part of a multisite, cross-sectional, observational cohort TBIMS addendum study on Chronic Pain. Extremely low and high pain phenotypes were identified by the Brief Pain Inventory (BPI) interference scale, and the Patient’s Global Impression of Change (PGIC). Clinical outcomes of interest included life satisfaction, posttraumatic stress, depression and anxiety symptoms, sleep and participation. Generally, extreme phenotypes based on interference had greater association with psychosocial outcomes compared to improvement-based phenotypes. Those identified as extremely high pain interference phenotype had poorer psychosocial outcomes compared to the extremely low phenotype group. After controlling for covariates, large effect sizes (ES) related to pain interference were observed for posttraumatic stress symptomatology (ES = -1.14), sleep quality (ES = -1.10), depression (ES = -1.08), anxiety (ES = -0.82), and life satisfaction (ES = 0.76); effect sizes for participation outcomes, although significant, were relatively small (ES = 0.21-0.36). Effect sizes related to perceived improvement were small for life satisfaction (ES = 0.20) and participation (ES = 0.16-0.21) outcomes. Pain intensity was identified as a meaningful confounding factor of the relationships between extreme phenotypes and posttraumatic stress, depression, anxiety, and sleep quality. Results suggest that the relationships among a variety of characteristics of the person, their experience with pain, and treatment of pain are complex. However, examination of subgroups defined by extreme phenotypes of interference (and to an extent, perceived improvement) were able to identify pronounced differences in the psychosocial experience of individuals living with chronic pain and TBI. Further research is needed to better understand these complex relationships and how differences in pain interference and perceived improvement from treatment can assist in assessment and treatment of chronic pain after TBI.
97 Anterior Prefrontal Cortex Resting-State Functional Connectivity Associated With Depressive Symptoms in Chronic Moderate-to-Severe Traumatic Brain Injury: A Preliminary Study
Layan Elfaki1,2; Bhanu Sharma3; Liesel-Anne Meusel2; Isis So4; Brenda Colella2; Robin Green1,2,5
1Temerty Faculty Of Medicine, University Of Toronto, Toronto, Canada; 2KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, Canada; 3Department of Medical Sciences, McMaster University, Hamilton, Canada; 4Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada; 5Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
Background & aims
Depression in the context of moderate-to-severe TBI (msTBI) is highly prevalent, but its neural underpinnings are little understood. This pilot study focused on this gap through exploring voxel-wise associations between depressive symptoms and anterior prefrontal cortex (aPFC) resting-state functional connectivity (rsFC).
Methods
In a secondary analysis, BOLD fMRI resting-state scans and Personality Assessment Inventory Depression scale (PAI-DEP) scores were acquired from the Toronto Rehab TBI Recovery Study database. We examined n=32 patients with chronic msTBI and n=17 age and education-matched healthy controls. Patients with TBI were operationally grouped as Depressed (n = 13) with PAI-DEP scores ≥ 60 or as Nondepressed (n = 19) with T-scores < 60. To compare bilateral aPFC rsFC across our three study groups, we performed F-tests through seed-based connectivity analyses, while controlling for age and education. Nonparametric permutation testing was performed with threshold-free cluster enhancement (TFCE) and family-wise error (FWE) correction to identify significant group differences.
Results
Although there were no significant differences in the rsFC of the right aPFC, the left aPFC demonstrated significantly increased rsFC with the bilateral fusiform gyri, right superior temporal lobe, and right precentral gyrus (TFCE-corrected pFWE < 0.05) in the group with comorbid TBI and depression as compared to the healthy control group.
Conclusions
This preliminary study adds to limited literature that implicates the aPFC in the pathophysiology of depressive symptoms occurring in chronic msTBI. Increased rsFC between the aPFC and these four sensory and motor regions could be a clue signifying vulnerability to depression post-TBI, offering testable hypotheses for future research.
99 Packed Red Blood Cell Transfusion: A Catalyst for Thrombosis in Patients With Traumatic Brain Injury?
Lily Nguyen1; Jeffry Nahmias1; Patrick Chen1; Jefferson Chen1; Michael Lekawa1; Jordan Shin1; Areg Grigorian1
1University Of California - Irvine, Orange, United States
Introduction
While blood transfusions can be lifesaving, they also carry risks including thromboembolic events. This is due to multiple factors including increased blood viscosity, inflammatory response to transfused blood, and changes in the coagulation cascade. Traumatic brain injury (TBI) exhibits a unique coagulopathy, which may predispose patients to both bleeding and clotting complications. Transfusing TBI patients may add an additional layer of complexity to their coagulation profile. Therefore, this study aimed to investigate the relationship between trauma patients with TBI who receive packed red blood cell (pRBC) transfusions and the incidence of venous thromboembolism (VTE) hypothesizing that transfusion of pRBC during the initial resuscitation increases the risk of VTE.
Methods
The Trauma Quality Improvement Program (TQIP) was queried from 2017-2021 to identify adult (>18 years-old) patients with TBI. Patients receiving pRBC transfusions were compared to those who did not receive pRBC transfusions within 4 hours of presentation. Patients that died or were discharged within 48-hours, and all transferred patients were excluded. Outcomes were compared using bivariate analyses and a multivariable logistic regression analysis to identify predictors of VTE while controlling for age, sex, obesity, vitals on arrival, surgical intervention and fractures to the pelvis, spine, and lower extremities.
Results
Of 422,831 TBI patients, 28,230 (6.7%) received pRBC transfusion. Patients who were transfused were younger (median: 45 vs 61 years old, p< 0.001), but had increased injury severity score ≥ 25 (72.5% vs 20.6%, p< 0.001) and a higher rate of emergent operations (39.4% vs 6.7%, p< 0.001). Transfused patients had higher rates of pelvic fractures (29% vs 4.4%, p< 0.001), spine fractures (50.8% vs 15.7%, p< 0.001), and lower extremity fractures (37% vs 8.6%, p< 0.001). Thrombotic events were more frequently observed in pRBC transfused patients, including cerebrovascular accident (2.7% vs 0.6%, p< 0.001), and VTE (8.1% vs 1.5%, p< 0.001) comprised of deep vein thrombosis (6.4% vs 1.2%, p< 0.001), and pulmonary embolism (2.4% vs 0.4%, p< 0.001). Multivariable regression analysis found undergoing any surgery (OR = 4.78, p<0.001) followed by transfusion of pRBC within 4 hours of presentation (OR = 1.438, p < 0.001) as the strongest predictors of VTE. Additional associated risk factors were ISS ≥ 25 (OR = 1.797, p< 0.001) and male sex (OR = 1.46, p< 0.001).
Conclusion
Trauma patients with TBI undergoing pRBC transfusion within 4 hours of arrival had an over 40% increased associated risk of VTE, compared to patients not undergoing transfusion. Providers should be vigilant in assessing the need for transfusions in TBI patients, balancing acute TBI management with thrombotic risks. Increased provider awareness of these findings may foster better patient outcomes by avoiding unnecessary transfusions in this high-risk population.
100 Prevalence of Concussion and Traumatic Brain Injury Secondary to Domestic and Intimate Partner Violence: A Systematic Review and Meta Analysis
Rachel Plouse1,2; Diego Martell2,3; Nicolette McNair1,2; Suzannah Henderson2,4; Edie Zusman2,5
1Touro University Nevada, Henderson, United States; 2Safe Living Space, San Francisco, United States; 3Yale University, New Haven, United States; 4University of California,San Francisco, San Francisco, United States; 5Neuroscience Partners, Moraga, United States
Background
Domestic violence (DV/IPV) is a pressing global issue, affecting 25% of women and 10% of men. In the US alone, 58 million men and women experience DV/IPV within their lifetime. The most common physical assault in DV/IPV events is injury to the head and neck, occurring in 50-80% of altercations. However, there is currently no standardized or routine evaluation of TBI in DV/IPV situations. Debilitating physical, behavioral, and cognitive symptoms can result from such injuries, interfering with the ability to perform daily tasks and increasing the long-term risk of Parkinson’s, Dementia and Chronic Traumatic Encephalopathy (CTE). The purpose of this meta-analysis is to evaluate the prevalence of TBI secondary to DV/IPV.
Methods
A PubMed search from September 2014, the publication date of neurosurgical concussion guidelines used for sports, to September 2022 was conducted using keywords domestic violence and/or intimate partner violence in conjunction with concussion, traumatic brain injury, and/or head injury. The resulting primary research articles were then selected based on the following inclusion criteria: participants were ≥ 18 years old, participants had experienced violence by an intimate partner, the screening tool included questions about signs and symptoms of TBI as well as an experience that could cause a TBI, and a TBI diagnosis was not required for inclusion in the study. Data collection was then performed. Inter-reviewer validation and risk of bias assessment were conducted to ensure validity of data collection.
Results
Of the 8,218 publications on domestic and/or intimate partner violence, only 46 (0.6%) included keywords concussion, traumatic brain injury, or head injury. Of those 46, 11 papers were included in this meta-analysis. From these 11 papers, the meta-analysis had a total sample size of 1,498. The prevalence of IPV-related TBI within this aggregated sample was 56.1% (n=841). Two studies with a total of 119 subjects included questions to evaluate the prevalence of multiple TBIs. In this subset, the prevalence of multiple TBIs was 50.4% (n=60). To assess for TBI prevalence, three papers utilized the Brain Injury Severity assessment (BISA), two studies used the HELPS tool, three performed a semi-structured interview, two utilized a modified VA TBI screening tool, and one used a modified Miller Abuse Physical Symptoms and Injury Scale (MAPSAIS).
Conclusion
There is a paucity of research into TBI within the DV/IPV population as well as a lack of standardized screening and evaluation. This meta-analysis suggests that more than half of people experiencing DV/IPV have sustained one or more brain injuries. Based on concussion research in sports, prospective studies are needed to optimize the screening, evaluation, and care of concussion and TBI within the DV/IPV population.
101 Multi-Session Transcranial Alternating Current Stimulation in Subacute Severe Brain-Injured Patients
Beatrice P. De Koninck1,2,3; Daphnee Brazeau1,2; Amelie Apinis-Deshaies2; Marie-Michèle Briand1,2,4; Charlotte Maschke3,5; Virginie Williams2; Caroline Arbour1,2; David Williamson1,2; Catherine Duclos1,2; Francis Bernard1,2; Stefanie Blain-Moraes3,5; Louis De Beaumont1,2
1University Of Montreal, Montreal, Canada; 2CIUSSS du Nord-de-l’Île-de-Montréal Research Center, Montreal, Canada; 3Montreal General Hospital, McGill University Health Centre, Montreal, Canada; 4Institut de réadaptation en déficience physique de Québec, Physical Medicine and Rehabilitation Department, Quebec, Canada; 5McGill University, Montreal, Canada
Introduction
Therapeutic interventions for disorders of consciousness (DoC) lack consistency; evidence supports non-invasive brain stimulation, but few studies assess neuromodulation in acute-to-subacute brain-injured patients. Interventions targeting the latter phase of DoC following a severe brain injury (i.e., severe traumatic brain injury (sTBI) or global hypoxic-ischemic encephalopathy (HIE)) may be critical to promote consciousness and long-term functional recovery. This study aims to validate the feasibility and assesses the effect of a multi-sessions transcranial Alternating Current Stimulation (tACS) intervention in brain-injured patients on recovery of consciousness, related brain oscillations and brain network dynamics.
Methods
This study was conducted in twelve medically stable brain-injured adult patients (sTBI and HIE), with a Glasgow Coma Scale score ≤ 12 after continuous sedation withdrawal. Recruitment took place at the intensive care unit (ICU) of a Level 1 Trauma Center in Montreal, Quebec, Canada. The intervention included a 20-minute 10-Hz tACS at 1 mA intensity or a sham session over parieto-occipital cortical sites, repeated over 5 consecutive days. The stimulation frequency targeted alpha brain oscillations (8-13 Hz), known to be associated with consciousness. Resting-state electroencephalogram (EEG) was recorded according to the intervention’s administration: pre- and post-intervention, at 60 and 120 minutes post-intervention. Two additional recordings were included: 24 hours and one week post protocol. Multimodal measures [blood samples, pupillometry, behavioral consciousness assessments (Coma Recovery Scale-revised), actigraphy measures] were acquired from baseline up to one week after the stimulation. EEG signal analyses focused on the alpha bandwidth (8-13 Hz) using spectral and functional network analyses. Phone assessments were conducted at 3, 6 and 12 months post-tACS to measure long-term functional recovery, quality of life, and caregivers’ burden.
Results
Results demonstrate the feasibility of a 5-day tACS protocol on subacute brain-injured patients in the ICU, as well as multimodal and long-term measurements without interfering with the care team and while preserving constant relatives’/caregivers’ adherence to longitudinal follow-up sessions up to 12 months post-injury. Functional connectivity measures, such as the weighted phase lag index and the directed phase lag index, along with network hubs and power topography (i.e., topographic network properties) in the alpha bandwidth, were shown effective in detecting changes throughout the repeated protocol. Brain activity changes are also reflected by behavioral improvements according to CRS-R assessments.
Conclusions
These initial results support the expansion of this study to a clinical trial including a sham stimulation to assess the efficacy of a repetitive tACS protocol on the modulation of alpha band activity, as well as recovery of signs of consciousness. This experimental design includes repeated, rigorous multimodal assessments to allow the optimal capture of subtle changes in consciousness recovery status. Finally, such a protocol may allow the identification of conditional endotypes of responders to develop a targeted intervention.
102 Rapid Blood- Based Dipstick Test for Mitochondrial Electron Transport Chain Damage and Severity of Blast TBI in Rats
Pushpa Sharma1; Geetaram Sahu2; Biswajit Saha3
1Uniformed Services University, Bethesda, USA; 2Uniformed Services University, Bethesda, USA; 3Uniformed Services University, Bethesda, USA
Background
Blast trauma is unique because of its complex mechanism of injury to the brain and other vital organs due to over pressure air and bleeding from internal organs. Severe loss of blood leading to hemorrhagic shock (HS) results in inadequate supply of oxygen and fuel to the cells for the generation of ATP from the mitochondria for the cell survival. Mitochondria generate ATP for cell survival through the orchestrated action of its electron transport chain enzyme’s activities, mainly through complex I-IV and mitochondrial gatekeeper enzyme” pyruvate dehydrogenase complex. Any damage to these enzymes results in increased oxidative damage to the cells, organ’s dysfunctions and neurological disorders. Although clinical symptoms of metabolic disruption are evident soon after the injury, but actual damage mechanisms at the molecular, cellular and organ system level persists for days to years post injury.
Objectives
1) utilize our rapid blood -based dipstick test to monitor the severity of mitochondrial electron transport chain damage in response to blast exposure and HS, and 2) develop mitochondrial targeted therapeutic strategies.
Method
Pre-clinical and military relevant rat model with blast exposure accompanied with or without HS and resuscitation was used. The animals underwent three repeated blast injuries of 20PSI at 15 minutes interval. After circulatory variables (MAP and pulse rate) were determined, controlled hemorrhage was induced. Rats were then bled over a 15-minute period to a MAP of 40 mmHg. Blood was collected in pre-heparinized tubes. MAP was sustained at 40 mmHg for 40 minutes by withdrawal or infusion of shed blood. Resuscitation (T60-120) followed by Blood Transfusion (T120-150). After the HS, animals were infused with either hypertonic sodium pyruvate (2M) or osmolality and volume matched control hypertonic saline. Blood collected at T0 (baseline), T60 (after injury), and T180 (end) was analyzed for plasma mitochondrial electron transport enzymes complex I, IV and pyruvate dehydrogenase by our published dipstick test.
Results
Compared with baseline values, a significant decreased activity of complex I, IV and Pyruvate Dehydrogenase Complex (PDH) was noted after blast and HS in all of the animal groups. The animals also had a significantly elevated plasma lactate concentration. Although pyruvate treatment was effective in preventing the loss of these mitochondrial ETC enzyme activities, and also corrected the hyperlactatemia at the end, but it was unable to restore them to the baseline levels, suggesting the need for a combined therapeutic strategy targeted at preventing the mitochondrial damage, inflammatory cascade, antioxidant, and cell death mechanisms.
Conclusions
Serial monitoring and optimization of blood complex I, IV and PDH activity could aid in prognostication and potentially guide in using mitochondrial targeted therapies to reduce the mortality from the severity of combined traumatic injuries associated with hemorrhagic shock.
103 Safety and Feasibility of Paired Robotic Tilt Table and Transcutaneous Auricular Vagus Nerve Stimulation in a Patient With Chronic Disorders of Consciousness: A Case Study
Jessica Polizzi1; Wilber Parada-Iraheta1; Gabriela Rozanski1; Christopher P. Kellner2; Neha Dangayach2; David Putrino1; Jenna Tosto-Mancuso1
1Department of Rehabilitation and Human Performance Icahn School of Medicine at Mount Sinai, New York, United States; 2Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, United States
Background
Rehabilitation for patients after severe acute brain injury (SABI) and subsequent disorders of consciousness (DOC) is a complex balance of restorative strategies and medical management. There is an emerging body of evidence supporting early mobilization and rehabilitation in the acute and subacute phases of rehabilitation after SABI, including the implementation of progressive upright mobilization to support arousal, attention, and hemodynamic stability. 1, 2 Further, new evidence suggests transcutaneous auricular vagus nerve stimulation (taVNS) as a potentially effective, non-invasive neuromodulatory therapy for patients with (DOC) in both acute and chronic stages. 3, 4, 5 Little is known, however, about the safety and feasibility of paired upright mobilization and taVNS interventions in the rehabilitation of patients with chronic DOC. This work reports on the safety and feasibility of robotic enabled upright mobilization with paired taVNS for a patient with chronic DOC following SABI.
Methods
Patient is a 50 year old male with no significant past medical history prior to diagnosis of SARS- CoV2 infection in June of 2022. Following recovery from acute respiratory symptoms, the patient began to experience new onset fatigue and shortness of breath. Medical examination identified pulmonary emboli. The patient was treated with surgical thrombectomy where he suffered an intraoperative myocardial infarct. He was subsequently diagnosed with a SABI and remains in a minimally conscious state to date. He was seen at the Abilities Research Center Advanced Technology Rehabilitation Program where he underwent 6 weeks of advanced technology physical therapy. Interventions included 2 sessions per week of progressive upright mobilization with robotic assisted-stepping using Erigo (HOCOMA) and paired taVNS (PARASYM). The first 5 weeks consisted of mobilization with Erigo alone, with the addition of paired taVNS during the 6th week. Safety and feasibility were assessed using adverse event reporting. Clinical outcomes were assessed using the Coma Recovery Scale-Revised (CRS-R) and Glasgow Coma Scale (GCS) at baseline and 4 weeks.
Results
The patient participated in 6 weeks of progressive verticalization with the addition of taVNS during the 6th week. No adverse events were reported. The patient tolerated an average of 32.36 (+/-12.14) minutes time on task. The patient tolerated an average tilt angle of 42.75 (+/- 26.66) degrees with a maximum tilt of 74 degrees. At baseline the patient scored 7/15 on GCS and 8/23 on CRS-R. At 4 week reassessment, GCS increased to 9/15. Overall CRS-R score remained 8/23 however motor function subscale score increased and arousal subscale decreased, each by 1 point respectively.
Conclusion
These findings suggest that robotic enabled mobilization with paired taVNS, is a feasible and safe intervention for persons with chronic DOC. Future work will continue to investigate short and long term feasibility, safety, and efficacy of the intervention in patients with chronic DOC.
104 Traumatic Brain Injury Among Veterans Accessing VA Justice-Related Services
Ryan Holliday1,2; Alexandra Smith1,2; Adam Kinney1,2; Jeri Forster1,2; Nazanin Bahraini1,2; Lindsey Monteith1,2; Lisa Brenner1,2
1Rocky Mountain Mental Illness Research, Education And Clinical Center for Suicide Prevention, Aurora, United States; 2University of Colorado Anschutz Medical Campus, Aurora, United States
Background
Risk for traumatic brain injury (TBI) within both the Veteran population and among individuals with a history of criminal justice involvement is notably high. Despite this, research examining TBI among Veterans with a history of criminal justice involvement (i.e., justice-involved Veterans) remains limited. Such a gap is disconcerting as the sequelae of TBI can impact justice-involved Veterans’ engagement in Department of Veterans Affairs (VA) justice-related services (i.e., Veterans Justice Outreach and Health Care for Re-entry Veterans), thus potentially increasing risk for recidivism and impacting post-release rehabilitation and psychosocial functioning. As such, further understanding of TBI risk among justice-involved Veterans is an integral first step to informing the potential need for tailored screening and interventional efforts within VA justice-related service settings. Given this, the current project sought to better understand relative risk for TBI diagnosis among male and female Veteran recipients and non-recipients of VA justice-related services.
Data Source
Data were gathered from electronic medical record data for Veterans accessing VA services from 2005 to 2018.
Sample
1,517,447 (12.48% justice-involved) male and 126 237 (8.89% justice-involved) female Veterans were included in the current cohort.
Study Design
The current project was a cross-sectional examination of national VA electronic medical record data. Sex-stratified analyses were conducted to examine relative risk of TBI diagnosis based on use of VA justice-related services.
Measures
Documented TBI diagnosis was the outcome of interest (as determined by ICD-9 and ICD-10 codes). Covariates included for adjusted models included: VA service use, age, race, and ethnicity.
Results
Both male and female Veterans accessing VA justice-related services were more likely to have a documented TBI diagnosis in their electronic VA medical record. Associations were attenuated, yet maintained significance, in all adjusted models.
Conclusions
Given relative risk for TBI, enhancing and tailoring care for justice-involved Veterans may be critical to facilitating rehabilitation and reducing recidivism. It is likely that military (e.g., combat exposure) and non-military (e.g., physical assault in prison; childhood abuse) likely contributed to notably high rates of TBI among this population. Examination of existing services within justice-related settings and methods of augmenting care is an important next step. More specifically, determining methods of further implementing TBI screening as well as addressing TBI-related sequelae in these Veterans may be a pragmatic and necessary approach.
106 Home Safety Concerns for Adolescents With Acquired Brain Injuries: A Mixed-Methods Study Among Key Stakeholders
Sarah Anderson1; Sarah Pierce1; Taylor Stamper1; Jennifer Lundine1,2; Carmen DiGiovine1; Emily Patterson1; Scott Swearingen1; Lauren Wengerd1; Amy Darragh1
1The Ohio State University, Columbus, United States; 2Nationwide Children’s Hospital, Columbus, United States
Background
Acquired brain injury (ABI) is a leading cause of death and disability among children and adolescents, who experience a variety of cognitive, motor, and functional impairments. These youth are at an increased risk for additional injury in the home and community environments.
Objective
We aim to identify the home safety concerns adolescents with ABI, caregivers, and healthcare providers have for these adolescents with ABI.
Methods
We recruited healthcare providers, adolescents with ABI, and caregivers of adolescents with ABI for this mixed-methods study. Participants completed questionnaires on demographics (including injury severity) and pre-identified home safety hazards. They also engaged in individual or group interviews to examine their clinical/rehabilitation experiences and home safety hazards and concerns. Finally, they participated in a self-identified hazard prioritization matrix activity. Questionnaire data were analyzed with descriptive statistics (mean, standard deviation, frequency, etc.), and interview recordings were transcribed and analyzed via qualitative thematic analysis. Matrix data were analyzed with both descriptive statistics (hazard frequencies) and qualitative analyses (coding and thematic analysis of hazard descriptions).
Results
Participants included thirteen healthcare providers (30.8% OT, 30.8% PT, 23.1% SLP, mean age 37.5 years), five adolescent patients with TBI (mean age 15.2 years), and five caregivers of adolescents with TBI (mean age 46.2 years). A percentage of the 67 pre-identified hazards were rated as concerning by at least one participant (100% providers, 26.9% caregivers, 31.3% patients). Self-identified safety hazards were 59 for providers, 21 for caregivers, and 10 for patients. In addition, 60% of patients identified no hazards, as compared to every provider and caregiver participant self-identifying at least one hazard. We found seven themes in hazards: hazardous activities, hazardous situations, hazardous objects, hazardous others, hazardous spaces, harms, and patient-specific factors (e.g., impulsivity).
Discussion
This research study elucidates the safety hazards that pose risks to adolescents with ABI after hospital discharge to their homes. While all stakeholders expressed concerns for this population, providers identified more hazards and higher levels of concern than patients and caregivers. These findings provide insights to improve home safety interventions delivered to adolescents with ABI and their families.
107 Stakeholder Perceptions of a Home Safety Virtual Simulation Training System for Adolescents With ABI
Sarah Anderson1; Sarah Pierce1; Taylor Stamper1; Jennifer Lundine1,2; Carmen DiGiovine1; Emily Patterson1; Scott Swearingen1; Lauren Wengerd1; Amy Darragh1
1The Ohio State University, Columbus, United States; 2Nationwide Children’s Hospital, Columbus, United States
Background
Acquired brain injury (ABI) is a leading cause of death and disability among children and adolescents, who experience cognitive, motor, and functional impairments. These youth are at an increased risk for injury in the home and community environments. However, few tools exist to reduce the risk of injury.
Objective
We aim to assess the usability, usefulness, and desirability characteristics of a previously developed home safety program, the Home Healthcare Virtual Simulation Training System (HH-VSTS), and then identify modifications to tailor the program to adolescents with ABI.
Methods
Individual or multiple participants viewed a real-time demonstration of the HH-VSTS or test-played it themselves. They simultaneously participated in semi-structured, recorded interviews that elicited suggestions for program improvements. Healthcare providers, adolescents with ABI, and caregivers of adolescents with ABI were recruited to participate in this mixed-methods study. Participants completed demographics (including injury severity) and HH-VSTS usability (examining usability, usefulness, and desirability) questionnaires. Transcriptions from the interviews were analyzed via qualitative thematic analysis, and questionnaire data were analyzed with descriptive statistics.
Results
Participants included thirteen healthcare providers (30.8% OT, 30.8% PT, 23.1% SLP, mean age 37.5 years), five adolescent patients with TBI (mean age 15.2 years), and five caregivers of adolescents with TBI (mean age 46.2 years). On a 1-7 numeric rating scale with 1 as not demonstrating that quality and 7 as very demonstrative of that quality, all participants rated the HH-VSTS as having good usability (mean 5.48/7), usefulness (mean 6.09/7), and desirability (mean 5.52/7). Patients consistently rated these qualities high, while clinicians and caregivers rated them lower. Themes were modifications to enhance HH-VSTS characteristics: learning, enjoyment, graphics, content, usability, and utility.
Discussion
We confirmed that participants, and particularly the intended user group, rated overall usability as moderate. We identified necessary modifications to improve the relevance, accessibility, and enjoyment of the HH-VSTS for adolescents with ABI. These findings provide insights to tailor the HH-VSTS for adolescents with ABI, while supported by their families and providers. Future research is anticipated to re-design, re-develop, and assess a revised HH-VSTS for this population. There are no conflicts of interest.
108 A Case Report: Anti-Inflammatory Supplementation Dramatically Improves Post-Neurosurgical Recovery in a Pediatric Patient Requiring Functional Hemispherotomy
Melissa Kopolow2; Michael Lewis1; Chima Oluigbo3
1Brain Health Education and Research Institute, Potomac, United States; 2Hydrocephalus Association, Bethesda, United States; 3Department of Neurosurgery, Children’s National Medical Center, Washington, United States
AM was a complicated 8-year old female with a three year history of intractable seizures unresponsive to numerous medications. Born a 25-week micropreemie, twin B, she suffered a bilateral intraventricular hemorrhage grade III/IV on day 2 of life resulting in hydrocephalus. By age 5, she had twelve brain surgeries, all related to hydrocephalus, before she developed new onset left hemisphere focal seizures. Following two unsuccessful thermal ablations of her left amygdala and hippocampus, the decision was made to undertake a functional hemisphereotomy, isolating her left hemisphere. Starting one month prior to surgery and continuing without interruption, the patient’s mother instituted a regimen of twice daily supplementation using an omega-3 fish oil product that also contained Curcumin Extract, N-Acetyl-Cysteine, and Reduced L-Glutathione. The eight-hour surgical procedure went without complication.
Normal protocol dictates three days in the PICU, one week on the neuro-ward monitoring CSF output, fever, and edema, all very common following this procedure. Following removal of the externalized drain, patients typically spend an additional two to six weeks in inpatient rehabilitation. This patient, however, asked for, and ate, a full meal immediately upon waking, spent only one night in PICU, and as she was ambulatory the next day, she was transferred to the neuro-ward. Instead of three to five days of edema and fever as is typical, the patient had less than 24 hours of edema, no fever, and drain was removed on day three making her eligible for discharge to home for outpatient rehabilitation. However, due to COVID, outpatient rehabilitation was unavailable, so the patient was kept for one-week inpatient rehab. No further seizure activity has been noted since, now over three years later, and has been off all medications for over two years.
Here we present a case of arguably the most radical neurosurgical intervention that typically requires minimum of three weeks hospitalization. In this particular instance, the outcome was dramatically altered where the patient was proactively placed on an anti-inflammatory supplement regimen before, during, and after hospitalization resulting in her eligibility for discharge to home in three days instead of three to eight weeks.
109 Targeting the Neuro-Inflammasome With Nutritional Therapy for TBI Management and Prevention
Michael Lewis1
1Brain Health Education and Research Institute, Potomac, United States
Managing concussions and TBI remains a complex challenge in sports medicine and healthcare. A one-size-fits-all approach isn’t going to work. While current standard of care primarily involves rest and symptomatic management, emerging research suggests that active recovery and specific nutritional strategies may expedite concussion recovery. Therapies targeting the inflammasome are essential to maintain or regain brain health after injury. Presented here is a comprehensive overview of the potential efficacy of targeted nutritional interventions in ameliorating the effects of concussions and diminishing the risk of recurring injuries.
There exists a complex interplay between omega-3s and omega-6s and the endocannabinoid system. The endocannabinoid system has well-established roles in neuroinflammation, synaptic plasticity and neurogenesis. The endocannabinoid system comprises cannabinoid receptors, their endogenous ligands, the endocannabinoids, and their biosynthetic and degradation enzymes. Arachidonic acid (ARA) and docosahexaenoic acid (DHA) are essential for optimal brain development and function with and through the cannabinoid system. Omega long-chain polyunsaturated fatty acids (LCPUFA), including ARA, DHA, and EPA (eicosapentaenoic acid), are essential components of membrane phospholipids and precursors to a number of bioactive lipid mediators. Anandamide (AEA) and 2-arachidonoylglycerol (2-AG) are the most widely studied endocannabinoids and are both derived from phospholipid-bound ARA. Yet, DHA and EPA supplementation reduce AEA and 2-AG levels, with reciprocal increases in levels of the analogous endocannabinoid-like DHA and EPA-derived molecules, docosahexaenoyl ethanolamide (DHEA) and eicosapentaenoyl ethanolamide (EPEA). Dietary enrichment with DHA and EPA have shown beneficial effects on learning and memory, neuroinflammatory processes, synaptic plasticity, and neurogenesis.
This review contributes to the evolving landscape of concussion management by highlighting the pivotal role of targeted nutritional therapy as a therapeutic approach. These interventions can modulate neuroinflammation, enhance neuroprotection, and facilitate neurorepair following a concussion. Furthermore, practical considerations for implementing targeted nutritional interventions across diverse populations, from athletes to military personnel and individuals at risk of recurrent head injuries, are to be addressed. This underscores the importance of acknowledging nutrition as a complementary strategy in the multifaceted domain of concussion management and prevention. As we persist in our endeavors to augment patient outcomes and alleviate the societal burden of concussions and TBI, the application of targeted nutritional interventions warrants further exploration and clinical integration within the field of traumatic brain injury.
110 The Use of Motion Capture Technology and the eTherapy App With Patients With Post-concussion Visual Gaze Deficits: A Case Study Design
Daniel Panchik1; Elizabeth Hice1; Conlin Shellenberger1; Shannon Young1; Angelo Botticelli1
1Elizabethtown College, Elizabethtown, United States
Introduction
The eTherapy app was created through a collaboration of computer engineering and occupational therapy and developed for patients with orthopedic injuries working on motor re-education. The app uses motion capture technology and a brand of inertia measurement units called Notches to measure a range of motion (ROM) and response time. The Notches are attached to the patient on both sides of a targeted joint and connected through Bluetooth to the mobile device with the app. This study finds novel uses for this app in patients with traumatic brain injuries. Concussion clients can experience long-term symptoms, including visual gaze deficits and changes in reaction time. They can also experience behavior or personality changes, including increased susceptibility to frustration1.
Methods
Researchers utilized a case study methodology with an expert opinion process2. The eTherapy app was introduced to an occupational therapist (OT) specializing in concussion rehabilitation and demonstrated its current capabilities. Then, researchers conducted a semi-structured interview with the OT about using the app for clients with vision deficits.
Results
In the interview, the therapist reported that the current functioning of the app and its crashes would increase frustration in concussion clients and slow down their progress. Through collaboration with the researchers, a method was developed to assess visual tracking by placing one sensor on the forehead and one on the back of the hand. The therapist also reported that the app’s margin of error when measuring ROM should be decreased. With the changes made, the OT believes that the app could be a useful tool for this population3. The app is portable and inexpensive, making it appropriate to use both in-clinic and as part of a home program.
Conclusion
Through expert opinion, we determined that if this app is to be utilized in a population with post-concussion visual gaze deficits, it should be further developed. It is viable to continue the development of the app in-clinic or in a home program with a client in this population. The app can calculate data for visual tracking and reaction time to gather objective information in real-time. The app’s final development must be consistent in its utility and function without the application crashing.
111 Longitudinal Evaluation of Gut Microbiome and Inflammation Among Those Seeking Care in the Emergency Department for Acute Mild Traumatic Brain Injury
Andrew Hoisington, Molly Pezenik, Kelly Stearns-Yoder, Christoper Lowry, Teodor Postolache, Claire A. Hoffmire, Marian Betz, Christopher Stamper, Jeri Forster, Lisa Brenner
1Department Of Veteran Affairs, Aurora, United States
Acute traumatic brain injury (TBI) exerts damage to the brain through an external force that activates a cerebral inflammatory response. In some cases, maladaptive inflammation may result in chronic inflammatory conditions and/or changes to the gut microbiome. Inflammation and the gut microbiome have a complex bidirectional relationship that plays a part in neurogenerative processes, behavior, and cognition. Currently few treatment options exist for TBI patients, therefore a better understanding of biological responses that are connected to physical and mental health outcomes is needed in human studies. In this study, longitudinal sampling was conducted from emergency department patients with post-acute mild TBI (mTBI). Samples included the fecal microbiome within 48 hours of admission (baseline) and at monthly intervals for up to 12 months in 23 participants for 167 total fecal samples (mean >7 samples per participant). Plasma was collected at baseline for all participants and at 12 months for a subset of 11 participants and analyzed for changes in inflammatory markers (i.e., C-reactive protein, interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor). Data regarding psychological histories/symptoms were obtained at baseline and each month of participation. Preliminary analysis was conducted to explore the microbiome and inflammatory changes post-acute mTBI. In a linear mixed model to account for related samples from the same participants, the overall microbial community was significantly divergent across the sampling time when compared to baseline. A rapid reduction in abundance, with no long-term recovery, of the potentially anti-inflammatory genus Akkermansia partially explained the trend. Akkermansia muciniphila promotes intestinal barrier function, in part by enhancing mucus production. A similar trend was not observed in other genera commonly associated with anti-inflammatory effects (e.g. Bacteroides, Faecalibacterium, Lactobacillus). Plasma concentrations of IL-6 were significantly reduced from baseline to 12 months, consistent with previous studies documenting elevated plasma concentrations of IL-6 immediately after a TBI. Findings support previous work highlighting relationships between TBI, inflammatory response, and the gut microbiome. Analysis of the factors associated with changes in the gut microbiome and/or biomarkers of inflammation is ongoing, including analysis of associations of physiologic responses with mental health outcomes subsequent to post-acute mTBI.
113 Disparities in Transitions of Care for Individuals with Traumatic Brain Injury
Amol Karmarkar1; Alexandra Ulbing, Charmi Kanani, Amber Walter
1Virginia Commonwealth University/sheltering Arms Institute, Richmond, United States
Navigating care following the initial hospital discharge can be a complex and vulnerable time for individuals with Traumatic Brain Injury (TB). After acute hospitalization, individuals with TBI may be discharged to different postacute settings, not limited to: inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), long-term acute care hospitals (LTCH), and home health (HH). When the right transitions are not made at the right times, individuals with TBI face poor outcomes such as hospital readmissions. Also, there exists disparity in these care transitions by gender, race/ethnicity, and living situation (rural versus urban settings). Our study objectives were, to examine care transitions patterns and differences for individuals with TBI in a 90-day post-hospitalization period, and to examine 30- and 90-day hospital readmission risk. This was a retrospective cohort study. We conducted secondary analysis of data from Virginia All-Payer Claims Database (APCD) for the years 2027-2021. Virginia APCD comprised of commercial, Medicare, Medicaid, etc. claims from about 5 million Virginia residents associated with health services (acute, postacute, and community-based) utilization. We selected records of individuals with TBI admitted to acute hospitals and followed their care transitions through postacute and community-based health services in 30- and 90-day follow-up period. We also calculated risk adjusted 30- and 90-day hospital readmission and examined if the hospital readmission risk is different by gender, race/ethnicity, locations, and type of postacute services they received, controlling for all the other covariates. Our analytical cohort comprised of 18,215 individuals with TBI with index acute hospitalization in the years of 2017-2021. The mean age of our cohort was 70.8 (18.7) years, 51% male, 33% non-white, and 5% living in rural locations. Only 61% (11,106) of our study cohort received any postacute care, with 30% going to SNFs, 18% to HHs, and 12% to IRFs. The unadjusted 30-day readmission rate was 3.6%, and 5% for 90-day hospital readmission. In the fully adjusted models, controlling for other covariates, we found higher likelihood of 30-day hospital readmission for those going to SNFs (OR=1.9, 95%CI=1.5-2.4), and IRFs (OR=2.9, 95%CI=2.3-3.8) relative to those without any postacute follow-up. Also, we found lower likelihood of 30-day hospital readmission for Blacks compared to non-Hispanic Whites (OR=0.68, 95%CI=0.50-0.93). For 90-day hospital readmission, we found higher likelihood with SNFs and IRFs discharges and lower likelihood for Blacks as compared to non-Hispanic Whites. Our study findings highlight need for equitable access to postacute care is an important consideration for individuals with TBI to maintain care continuity, and achieve desirable health outcomes, and more importantly avoidance of undesirable outcomes, such as hospital readmissions.
114 Heads Together - Understanding Acquired Brain Injury: An Interdisciplinary Collaboration Addressing the Knowledge and Skills Gap in Social Work Education to Improve Practice and Outcomes
Akudo Amadiegwu2; Caroline Bald2; Andrew Bateman2
1Canterbury Christ Church University, Canterbury, United Kingdom; 2University Of Essex, Colchester, United Kingdom
Brain Injury is the leading cause of death and disability in the UK for people aged 0-40 (Centre for Mental Health “CMH” 2018) and diagnosed in 70% of all cases of head injury (Ponsford, Sloan and Snow 2013). However, there is limited knowledge and understanding about this topic (Norman 2020, Mantell 2017) with very little known about social care and social work with people with brain injury (Holloway 2020) even though, social work plays an important role in the assessment and treatment of people with this condition (Linden et al 2023). The complexity and hidden nature of the condition can lead to misdiagnosis and inappropriate care and support. Safeguarding Adult Reviews repeatedly identify social workers’ poor understanding of ABI as a contributing factor to the premature deaths of people who struggle post-injury. Heads Together is an interdisciplinary effort led by Prof. Andrew Bateman and other brain injury experts and researchers including psychologists, social workers, academics from 5 universities in the UK and experts by experience funded by the NIHR with the aim of addressing this knowledge and skills gap. This unique project has five work packages including a systematic review of existing brain injury social work literature recently accepted for publication. Topic: Social workers’ understanding of acquired brain injury: A systematic review of the current evidence-base. We have surveyed 152 students, 65 social work educators and interviewed newly qualified and experienced social workers and commissioners in the UK to inform outputs. A recent addition to our project is Making Headway, a play in collaboration with local specialist brain injury charities brings the brain injury experience to life and serves as a trans-disciplinary teaching tool for health and social care students and other disciplines.
The play is supported by actor-led, interdisciplinary student workshops shown to over 150 University of Essex students in March, phase two is to tour four universities reaching 600 students by April 2024. Making Headway was presented at a Think Tank at the IBIA World Congress on Brain Injury in Dublin, with members of the team making presentations at this and other conferences including the Joint Universities Social Work Education Conference in Glasgow and has been nominated for a global interprofessional award. The team has influenced policy by contributing to two UK Parliament Post Notes and NICE Guidelines reviews and training social workers in a local authority where a safeguarding adult review into the death of a person with ABI was conducted. Heads Together is developing practice improvement resources including a website and interactive modules which present brain injury in a clear and concise manner and ultimately, improves outcomes for people affected by ABI. The brain injury social work toolkit will be launched during World Social Work Week 2024.
115 Social Work Educator Views of Student Training Needs in Preparation for Supporting People With ABI
Akudo Amadiegwu2; Caroline Bald2
1Canterbury Christ Church University, Canterbury, United Kingdom; 2University Of Essex, Colchester, United Kingdom
Social work education in the United Kingdom is governed by four regulatory bodies with no common curricula, with Social Workers in England alone undertaking multiple education routes in 82 higher education institutions (HEI). A growing body of evidence has demonstrated a potentially significant gap in Acquired Brain Injury (ABI) curricula inclusion in initial social work education. Little is known about the gap at a micro curriculum level or Social Work Educators’ views of ABI relevance in initial education. An intra-disciplinary, UK-wide NIHR funded project, Heads Together, is researching social work education curricula to evidence the preparedness of graduating social workers for ABI practice and to develop resource database for curricula development. As part of the research project, a 12-point online survey was deployed to UK-based Social Work Educators with the support of the Joint Universities Social Work Committee (JUSWEC) and the British Association of Social Workers (BASW). Thematic analysis of 28 responses found four key themes: 1) an acknowledged gap in ABI curricula inclusion in initial social work education including that of respondents; 2) a significant numbers of respondents had personal experience of ABI (self, family, or close friends); 3) a majority viewed that ABI should be mandatory part of initial social work education; and finally, 4) there are pockets of good practice often prompted by local practice. The survey findings will, in combination with interviewing newly qualified, specialist and commissioning social workers, inform curricula inclusion of ABI in social work education in the UK. Underpinning and guiding the project is a governance board of experts by experience including people with brain injury, family, and brain injured social workers.
117 Opioid Weaning in a Patient With Anoxic Brain Injury After a 273-Day Inpatient Hospitalization: A Case Report
Harry Liu1; David Ibrahim2; Alexander Turfe1; David Rustom1
1Wayne State University/Rehab Institute of Michigan, Royal Oak, United States; 2MSU College of Osteopathic Medicine, East Lansing, United States
Case Diagnosis
Opioid weaning in a patient with anoxic brain injury and an extensive hospital stay.
Case Description
A 33-year-old male with an anoxic brain injury, related to complications after a gunshot wound (entry through ear into posterior cervical spine) was admitted to our hospital after discharge from a long-term care facility. He had tracheostomy, gastric feeding tube placed and was ultimately ventilator dependent. Upon nearing his discharge from prolonged hospital stay, our PMR/Pain management team was consulted. His pain regimen included Hydromorphone 0.5 mg Q4H prn, Acetaminophen 650 mg Q6H, Methocarbamol 1000 mg Q8H prn, Gabapentin 300 mg TID, and a Fentanyl patch 75 mcg/hr Q72H. Hypotension was an issue and made pain control even more challenging. Our goal on hospital discharge after nearly 273 days of admission was to be off intravenous medications and to reduce his overall morphine equivalent dose. We evaluated pain primarily via facial grimacing, as communication was limited due to his orientation, and his tetraplegic status. His total pre weaning morphine equivalent dose was 279. Over the course of 5 days, we were able to reduce morphine requirements to 150, while eliminating his intravenous medications.
Discussion
Opioids should be used sparingly and every attempt for weaning should be made possible. They have been shown to further complicate treatment, worsen respiratory/cognitive status and have known to become an issue when attempting to wean if they have been administered over long periods of time. Additionally, higher morphine equivalent doses can lead to suppressed respiratory drive, dysautonomia, and decreased arousal, all issues we try to avoid potentiating in traumatic brain injury. Painful syndromes are characterized in traumatic brain injury and are challenging to diagnose, treat, and witness responses to treatment. Although localization may be difficult with nonverbal patients, we can use family, nursing staff, and physical examination maneuvers while monitoring for grimacing, blood pressure fluctuations, and mentation changes. Conservative pain-relieving options include pressure relief, correction of posture deficits, bracing, manual therapies, and non-opioid medications. If these fail, we do resort to the use of opioids and suggest beginning with the least restrictive dose, limiting progression or increases to tolerance.
Conclusion
Opioid weaning strategies should be employed early on in the treatment plan and attempted several times over. It can be discouraging and so we suggest slow weaning protocols varying from 10-20% reductions over the course of several days in a supervised setting.
118 Communication Partner Training for Health Care Workers, Families, Friends and Community Agencies Who Interact With People With Acquired Brain Injury: Pilot Data for a Free Online Resource Called Interact-ABI-lity
Leanne Togher1; Petra Avramovic1; Melissa Brunner1; Emma Power2; Sophie Brassel1; Rachael Rietdijk1
1The University of Sydney, Sydney, Australia; 2The University of Technology, Sydney, Australia
Background
Communicating with people with acquired brain injury (ABI) can be challenging given that 75% of people experience social communication impairments (Macdonald, 2017). These difficulties can lead to less successful and less enjoyable interactions with others, including family and health professionals. To address these difficulties, it is internationally recognized best practice that the communication partners of people with a brain injury should receive education about how best to support communication (Togher et al., 2023). This paper presents pilot data for a free communication partner training (CPT) program called interact-ABI-lity.
Method
Interact-ABI-lity is a self-guided resource which provides education to family members, friends, and health professionals who interact with a person with an ABI. It was developed via collaborative design and pilot testing (Miao et al., 2022). interact-ABI-lity is a two-hour, web-based CPT program for partners of adults with cognitive-communication disorders, aphasia or dysarthria after ABI. The free, seven-module program is available on desktop, tablet and phone devices as part of the ‘Social Brain Toolkit’. The pilot study entailed the recruitment of two groups: 1. Eleven participants (six support workers, three clinicians, two student health professionals) who were interested in improving their skills, and 2. Five clinicians (two speech pathologists, one occupational therapist, one physiotherapist, one psychologist) with at least four years’ experience working with an ABI caseload. Data collection for group 1 included the number of people who completed the course, their ratings of the likelihood to recommend the course to others and their ratings of their confidence in interacting with people with TBI, and for the clinicians, feedback interviews were also conducted at course completion.
Results
Of the 11 learners in group 1, five fully completed the training, while all participants in group 2 fully completed all modules. Of the five completers, four learners rated their likelihood as 10/10 to recommend the course to others and three reported increased confidence in interacting with people with ABI at the end of the program. Feedback included the need for additional demonstration videos and provision of definitions of the technical language used.
Discussion
interact-ABI-lity may address the need for a short, accessible educational resource about how to communicate with a person with an ABI. The pilot testing process was informative to identify ways to improve interact-ABI-lity. These included building in motivators (e.g., certificate of completion), prioritizing development of videos of people with ABI and their family members, and specific additions to the course content (e.g., glossaries of technical terms). Since this pilot study, the program has been updated and the final version will be presented at NABIS. Since launch in Feb 2022, there have been 2280 registrations for interact-ABI-lity, and it is now incorporated into training for assistants, clinicians, and students internationally.
120 Developing an Animal Model of Coal Mine Gas Explosion and Understanding the Injury Mechanism
Linqiang Tian1,3; Zihui Zhao1,3; Tingting Lei1,3; Zhaodong Wang1,3; Zhenzhou Sun1,3; Hongxia Xing1; Jianan Chen2; Jie Liu1,3; Wenjie Ren3
1The 3rd Affiliated Hospital of Xinxiang Medical University, Xinxiang, China; 2School of Biological Science and Medical Engineering, Beihang University, Beijing, China; 3Clinical Medical Center of Tissue Engineering and Regeneration, Xinxiang Medical University, Xinxiang, China
Background
Although safety of coal mine production facilities and regulations continue to improve around the world, gas explosion accidents still exist. Brain damage caused by coal mine gas explosions is a unique type of injury that is different from those that are generally seen by the explosions in wars and open spaces. Specifically, it is caused by the gas explosions from the superposition of repeated shock waves in a closed space and subsequent poisonous gases such as carbon monoxide (CO), which is a particular combination of physical and chemical injuries. Currently, there are many models of simple explosion shock wave or CO poisoning separately, and it was also reported both experimentally and clinically that these injuries do not only cause neurological dysfunction in acute phase but is also more susceptible to develop neurodegenerative diseases in later stage. However, animal model of coal mine gas explosions with combined injuries does not exist currently, which prevent us from better understanding the difference between the single and combined injuries. We speculate that the combined injuries in coal mine gas explosions are more complex and severe than single injuries. This study will develop an animal model of gas explosion with combined injury by simulating gas explosion condition in coal mine tunnel and use the model to understand the injury mechanism. We believe that the results will be useful for finding effective intervention methods and early treatments for patients in coal mine gas explosion accidents in the future.
Methods
20 adult Kunming white mice were divided into four groups: (1) Single gas explosion (SGE), received one explosion in a customized device; (2) Continuous CO poisoning (CCP), received four CO intraperitoneal injections within 24 hours; (3) SGE+CCP, received single explosion immediately followed by four CO injections within 24 hours; (4) Normal control (NC), received no injury. Behavior tests were performed three and seven days after injuries, then the animals were terminated for molecular biology tests.
Results
The elevated plus maze test shows that in both 3 days and 7 days after injury，all injured groups presented significantly lower entering number when compared to NC group (P < 0.05); while SGE+CCP group also presented significantly lower entering number when compared to SGE and CCP groups (P < 0.05). RT-qPCR test shows that the brain tissues from SGE+CCP group presented significantly higher expression of IL-1β and TNF-α in 3 days after injury as well as higher expression of IL-6 and TNF-α in 7 days after injury when compared to other groups (P < 0.05).
Conclusions
A mouse model of coal mine gas explosion was developed. The combined injury was found to be more severe than the single injuries behaviorally, which may be related to the more severe inflammation.
122 Rethinking the Outcomes and Burden of Diffuse Axonal Injury: A Nationwide Analysis
Amelia Maiga1; Shayan Rakhit1; Kun Bai1; Fei Ye1; Areg Grigorian2; Bellal Joseph3; Susanne Muehlschlegel4; Mayur Patel1
1Vanderbilt University Medical Center, Nashville, United States; 2University of California, Irvine, Irvine, United States; 3University of Arizona, Tucson, United States; 4Johns Hopkins, Baltimore, United States
Introduction
Diffuse axonal injury (DAI) is a subtype of traumatic brain injury (TBI) thought to portend poor outcomes, perhaps prompting early withdrawal of life-sustaining therapies. However, large-scale studies are limited. Because DAI can be subtle or invisible on initial head CT imaging, diagnostic delay is common until other causes of encephalopathy are ruled out and MRI can be performed safely. We hypothesized that TBI with DAI would have increased in-hospital mortality compared to comparable TBI without DAI in a large nationwide database.
Methods
This retrospective cohort study included adults from the 2017-2020 American College of Surgeons Trauma Quality Improvement Program admitted with blunt, moderate-severe TBI. Exclusion criteria were bilateral nonreactive pupils. We compared patients with and without DAI and adjusted for age, injury severity score (ISS), presenting hemodynamics, TBI severity, and hospital characteristics. Logistic regression was used for the binary outcomes of inpatient mortality and hospital discharge disposition (proxy for short-term functional status). Linear regression was used for the continuous outcomes of time to intracranial pressure monitor (ICPm) placement and hospital length of stay (LOS).
Results
Of 65,448 patients with moderate-severe TBI (median GCS 8 [interquartile range, IQR 6,10]), 7765 patients (12%) had DAI. DAI patients were significantly younger (median 36 years [25,55] vs. 55 years [32,71]) with higher ISS (33 [26,38] vs. 25 [17,29]), less midline shift (16% vs. 30%), and higher ICPm usage (43% vs. 24%, p<0.01). In multivariable analyses, DAI was associated with lower inpatient mortality (odds ratio [OR] 0.967, 95%CI 0.956-0.978), a 3.2-hour delay in ICPm placement (95%CI 0.1-6.3h), more than 3 days longer LOS (95% CI: 3.33-4.18), and worse short-term functional status (OR 1.06, 1.05-1.07) as measured by hospital discharge disposition.
Conclusion
Previous beliefs about early mortality and withdrawal of life-sustaining care for DAI are challenged by our findings. Further research is needed to clarify reasons for delays in ICPm placement (e.g., diagnostic delay, fatalism, etc.), and to determine if ICPm placement even improves outcomes in DAI. Although DAI prolongs hospitalization and is associated with worse functional status at discharge, the long-term trajectories of recovery remain unknown.
123 Gender Differences in Patients With Traumatic Brain Injury – A Retrospective Pilot Analysis
Jeffrey Lam Shin Cheung1; Hajer Nakua2; Anil Dosaj3; Shweta Aswani3; Ananya Pathak4; Fallon Ponnambalam3; Jeffrey Smallbone1; Myriam Vigny-Pau1; Shree Bhalerao3
1Faculty of Medicine,University of Toronto, Toronto, Canada; 2Institute of Medical Science, University of Toronto, Toronto, Canada; 3St. Michael’s Hospital, Toronto, Canada; 4University of Guelph-Humber, Etobico*ke, Canada
Purpose
In recent years, the incidence of traumatic brain injury (TBI) in Canada has doubled, with females having a higher prevalence. Current literature shows no consensus regarding how gender may influence post-TBI outcomes, thus prompting further investigations. Here, we sought to study whether gender impacts post-TBI outcomes specific to psychiatric well-being.
Methods
A retrospective cohort study of patients admitted to St. Michael’s Hospital for TBI was analyzed. Using health consultation reports, we collected patient demographic characteristics, cause of TBI, past medical history, diagnoses following TBI and treatments. All measures analyzed were qualitative and coded as no or yes (e.g. suffered from depression: no or yes). Chi-square tests were used to assess whether males or females had differing TBI. Multiple comparisons were corrected for using the Bonferroni Correction.
Results
Data was collected and analyzed for 39 patients (n=16 males, n=23 females, mean age = 38.5 ± 12.7 years). The causes of TBI included 16 (41.0%) motor vehicle accidents, 8 (20.5%) pedestrian accidents, 3 (7.7%) bicycle accidents, 10 (25.6%) cases of falls, 5 (12.8%) cases of physical assaults, and 3 (7.7%) sports-related injuries. Long-term disabilities resulting from TBI occurred in 14 patients (35.9%). Females were significantly more likely to experience orthopedic issues resulting from TBI compared to males (X2 = 5.35, p = 0.021), but this significance did not make it past multiple comparison corrections. No other significant differences were noted.
Conclusion
We did not find better post-TBI outcomes specific to psychiatric well-being in either gender in this pilot retrospective analysis. A larger sample and quantitative data are necessary to substantiate the findings.
124 The Boston Assessment of Traumatic Brain Injury Lifetime, Second Edition (BATL-2): Development and Initial Psychometric Evaluation in Post-9/11 Military Veterans
Catherine Fortier1,2,3; Alexandra Kenna1; Tristan Colaizzi1; Alyssa Currao1; Christine Clermont1; William Milberg1,2,3
1Translational Research Center for TBI and Stress Disorders (TRACTS), VA Boston Healthcare System, Boston, United States; 2Department of Psychiatry, Harvard Medical School, Boston, United States; 3New England GRECC, Boston, United States
The BATL is an extensively validated and widely used semi-structured clinical interview designed to diagnose traumatic brain injury (TBI) across the lifespan in post-9/11 military veterans with particular attention to blast-related injury. The BATL uses a forensic approach designed to differentiate clinical symptoms of TBI (e.g., altered mental status, posttraumatic amnesia, loss of consciousness) from other common physiological and psychological reactions to head injury and trauma. The BATL has been updated to: (1) incorporate the most up-to-date TBI diagnostic criteria (American Congress of Rehabilitation Medicine [ACRM] 2023; Veterans Affairs [VA]/Department of Defense [DoD] Clinical Practice Guidelines); (2) assess for subconcussive repetitive head injury risk from blast and blunt force trauma; and (3) offer a flexible battery approach to allow clinicians and researchers to select modules specifically tailored to high-risk TBI contexts (e.g., military, civilian, intimate partner violence, and sports). These changes will expand the breadth of context in which the BATL can be utilized and reduce time burden for administering the BATL interview based on research and clinical goals. Prevalence of injury using the BATL-2 will be presented for a large cohort of U.S. Veterans from the Translational Research Center for TBI and Stress Disorders (TRACTS), a 15-year, 2-site VA Rehabilitation Research and Development National Center for TBI Research. The sample consists of 878 combat exposed post-9/11 Veterans, 90% male, 71% Non-Hispanic White, with mean age of 35 (SD = 9.2) and mean education level of 14 years (SD = 2.2). On average, they served in 1.68 tours (SD = 1.1) for 16 months (SD = 11.2) and completed the BATL interview 70 months (SD = 52.0) after returning from their last deployment. TBI was highly prevalent, as 74% (n = 645) sustained a TBI in their lifetime and 54% (n = 474) sustained a TBI during military service. Additionally, 32% (n = 284) of Veterans sustained a blast force military TBI, while 33% (n = 290) sustained a blunt force military TBI. Data on subconcussive blast and blunt exposure were collected in a subset of 228 of these veterans, revealing that 60% (n = 137) reported exposure to subconcussive blast events and 43% (n = 99) reported exposure to subconcussive blunt force trauma. Results of an initial psychometric evaluation of BATL-2 scores in 2 samples of military veterans will be presented. Overall, results indicate that the BATL-2 is a psychometrically sound measure of both ACRM 2023 and VA/DoD TBI diagnosis and symptom severity. Importantly, the BATL-2 strongly corresponds with the BATL-1, suggesting the BATL-2 provides continuity in evidence-based assessment of TBI with the transition to ACRM 2023 criteria.
125 Recidivism Risk in Incarcerated Individuals With Traumatic Brain Injury in Relation to Aggression and Executive Functioning
Devan Parrott1; Dawn Neumann1; Anthony Laffooon1
1Indiana University School of Medicine, Greenwood, United States
Objectives
To examine aggression, executive functioning, and recidivism risk in a sample of incarcerated males with traumatic brain injury (TBI).
Methods
Cross-sectional study including 89 males with TBI. Data was collected as a baseline assessment for a clinical trial. Participants were recruited within 12 months of anticipated release date.
Measures
The Aggression Questionnaire (AQ) total score was used to assess aggression in addition to the verbal and physical aggression subscales. The Behavioral Rating Inventory of Executive Function-Adult Version (BRIEF-A) was used to measure self-regulation. The Level of Service Inventory–Revised (LSI-R) is a structured interview for correctional populations used to predict recidivism risk, adjustment, and institutional misconduct using criminal history, education, employment, finances, relationships, alcohol and drug problems, emotional/personal factors, and attitudes.
Results
The majority of the sample (59%) reported high-very high aggression (T-scores = 60) on the total AQ (mean T-score = 59.93, 95% CI [57.95, 61.91]). 54% of the sample reported high-very high verbal aggression (mean T-score = 56.55, 95% CI [54.58, 58.53]) and 51% reported high-very high physical aggression (mean T-score = 58.89, 95% CI [56.40, 61.39]). Scores on the BRIEF-A were also clinically significant with a mean Global Executive Composite (GEC) T-score of 68.80 (95% CI: [65.95, 71.66]) indicating significant difficulty with executive functioning. The Behavioral Regulation Index (BRI) was also elevated (mean T-score = 69.70, 95% CI [67.07, 72.33]) suggesting increased deficits related to inhibiting impulsive responses and controlling emotions and behavior. The Metacognition Index (MI) was also above average (mean T-score = 66.03, 95% CI [62.90, 69.16]) suggesting impairments related to self-management of tasks and self-monitoring. The sample also showed an increased recidivism risk with a mean LSI-R score of 29.77 (moderate risk), 95% CI [28.26, 31.27] and the majority of the sample (86%) scoring in the moderate or higher risk categories. LSI-R risk scores were significantly correlated with AQ total aggression (r =.404; p<.001) and physical aggression (r=.393; p<.001), but not verbal aggression (r = .081; p=.498). LSI-R scores were also significantly correlated with executive function impairment: GEC (r =.489; p<.0001), BRI (r =.494; p<.0001), and MI (r =.446; p<.0001).
Conclusions
Aggression and executive dysfunction are common consequences of TBI that are believed to contribute to high incarceration and recidivism rates. The results from this sample suggest that incarcerated individuals with TBI are more likely to display elevated levels of aggression as well as suffer from executive dysfunction. Furthermore, the significant linear relationships between aggression (especially physical) and executive functioning with recidivism risk highlight the need for interventions designed to address and mitigate these deficits in individuals with TBI within the corrections environment as a strategy to potentially reduce recidivism and reincarceration.
126 The STEP-Home Skills-Based Group Reintegration Workshop Improves Anger, Inhibitory Control, and Neurobehavioral and Mental Health Symptoms in Veterans With TBI and Other Common Comorbidities
Alexandra Kenna1; Dylan Katz1; Caroline Sablone1; Alyssa Currao1; Adam Lebas1; Catherine Fortier1,2
1Translational Research Center for TBI and Stress Disorders (TRACTS),VA Boston Healthcare System, Boston, United States; 2Department of Psychiatry, Harvard Medical School, Boston, United States
Background
Post-9/11 U.S. Veterans are clinically complex with multiple co-occurring health conditions contributing to morbidity/mortality and decreased quality of life. Traumatic Brain Injury (TBI) diagnosis can worsen these outcomes. STEP-Home is a cognitive-behavioral transdiagnostic intervention for TBI and common comorbidities.
Objectives
Determine if STEP-Home improves anger and impulse control, frontal system function, civilian readjustment, neurobehavioral symptoms, and work/life functioning in post-9/11 Veterans. TBI may influence Veterans’ ability to learn core skills and, thus, impact response to treatment. Treatment outcomes for Veterans with and without TBI will be explored.
Methods
A total of 56 (39M/17F; mean age = 40) post-9/11 Veterans with high rates of psychiatric comorbidity, with and without TBI received 12 weeks of the STEP-Home transdiagnostic group intervention. STEP-Home sessions teach cognitive behavioral skills relevant across diagnostic category, including Problem Solving (PS) and Emotional Regulation (ER). These skills are integrated and applied across Veteran-specific content areas to assist in community reintegration and functioning. Assessments at baseline, posttreatment (12 weeks), and follow-up (24 weeks) included: State-Trait Anger Expression Inventory 2 (STAXI-2); Military to Civilian Questionnaire (M2CQ); Post-Deployment Readjustment Inventory (PDRI); Frontal Systems Behavioral Scale (FrSBe); Neurobehavioral Symptom Inventory (NSI); World Health Disability Scale (WHODAS); PTSD Checklist (PCL-5); Depression Anxiety and Stress Scale (DASS-21).
Results
STEP-Home significantly improved anger expression (STAXI-2 p = .0320), inhibitory control (FrSBe p =.0001), and reintegration status (MC2Q p=.0001; PDRI p =.0097) posttreatment. Similar improvements were seen in neurobehavioral symptoms, work/life functioning, PTSD, depression, and stress (p’s < .01). Treatment gains were maintained at follow-up (p < .001). Treatment response did not differ by TBI status.
Conclusions
STEP-Home teaches Veterans cognitive-behavioral skills to improve anger, impulse control, executive functioning, reintegration, and work/life functioning. STEP-Home is equally as effective for participants with and without TBI. There was no effect of TBI status on treatment maintenance over time. This is critical given TBI prevalence among post-9/11 Veterans and the need for additional palatable treatment options.
128 Advancing a Precision Medicine Approach to Traumatic Brain Injury Longitudinal Outcomes Research
David Cifu1; Lisa Brenner2; Maya O’Neil3; Elisabeth Wilde4; Catherine Fortier5; William Milberg6
1Virginia Commonwealth University; Central Virginia VA Healthcare System, Richmond, United States; 2University of Colorado; VA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, United States; 3VA Portland Health Care System; Oregon Health and Science University, Portland, United States; 4VA Salt Lake City HealthCare System; University of Utah, Salt Lake City, United States; 5VA Boston Healthcare System; Harvard Medical School, Boston, United States; 6VA Boston Healthcare System; Harvard Medical School, Boston, Unites States
Traumatic brain injury (TBI) exposures and poor health and functional outcomes are well established, particularly in the context of traumatic stressors common among those with histories of military deployments. Our team is advancing precision medicine approaches to predicting longitudinal outcomes through largescale, multi-study data harmonization and machine learning analytics. We combined data from the two largest mild TBI (mTBI) longitudinal cohort studies: The Long-Term Impact of Military-Relevant Brain Injury Consortium Chronic Effects of Neurotrauma Consortium (LIMBIC) Prospective Longitudinal Study (PLS) is a 10-year, 17-site cohort of more than 2,800 combat exposed service members and veterans. The Translational Research Center for TBI and Stress Disorders (TRACTS) is a VA RR&D National Center for TBI research including a 15-year, 2-site longitudinal cohort study of more than 950 combat exposed veterans. This proof-of-concept, precision medicine approach to mTBI longitudinal outcome research includes: 1) defining standardization methods and creating a crosswalk for the modalities and domains of LIMBIC and TRACTS longitudinal cohorts to create a unified assessment profile; 2) identifying a rigorous harmonization approach to allow for overall data analyses using the unified data set; 3) developing a multi-modal, analytic approach for the harmonized data sets; 4) pilot testing the use of a VA-supported machine-learning approach to identify multimodal patterns relevant to predicting long-term posttraumatic brain health; 5) establishing a program of research to analyze the prospective, longitudinal dataset and enable identification of risk factors associated with brain disorders and recovery; and, 6) developing, pilot testing, and proposing follow-up “FAIR” (Findable, Accessible, Interoperable, Reusable) data methods to apply the systems developed in this proposal to incorporate additional relevant, largescale, longitudinal veteran/military data (e.g., Million Veteran Project, VA Electronic Health Record Corporate Data Warehouse) to this robust data resource. We will present harmonized biomarker, imaging, functional, and mental health meta-data, outcomes, and methods designed to be scalable and publicly accessible to further advance precision medicine analytics for TBI.
129 Establishing Therapist Training and Fostering Interdisciplinary Care for Evaluation and Treatment of Patients With Disorders of Consciousness
Emily Axelson1; Allison Bauer1; Kayla Johnson1
1Mayo Clinic, Rochester, United States
Patients with disorders of consciousness (DOC) are a population within the rehabilitation team’s scope of practice, but about whom limited education may be available to the therapy staff designated to support them. This was recognized as an area for development and efforts were undertaken to support more systematic, effective, and evidence-based approach to evaluation and treatment. This presentation will describe the development and implementation of procedures for allied health staff’s involvement in evaluating and treating patients with DOC. A survey with eight questions was distributed to 18 therapy staff at Mayo Clinic in Rochester, asking them to rate their confidence level in evaluating, treating, and reporting results to medical staff or patient’s family. Staff rated their confidence level on a scale of one-five where one was “not confident requires full supervision” and five was “confident, provides training to others.” We asked each participant to rate their familiarity with terms associated with this patient population, where one was “this term is unfamiliar” and five was “I could provide education on this term.” Of 18 therapy staff, 15 responded and their data is included here. Initial data gathered indicates 66.7 percent of occupational therapists (OT), physical therapists (PT), and speech-language pathologists (SLP), who are currently evaluating/treating these patients feel they require some level of supervision and are not independent. 86.7 percent reported that they were not confident in reporting the results of their evaluation to other medical professional or patient’s family. Lastly, 26.6 percent of participants reported no training outside of what was provided in their curriculum or did not have education specific to DOC in their program, and 40 percent reported no additional training outside of on-site orientation/mentorship. Despite limited experience and education, the expectation is to provide quality care to patients with these complex diagnoses. This gap in knowledge and comfort revealed therapeutic approaches that were inconsistent across the therapy team and did not align with the recommended best practice guidelines published in 2018. To optimize knowledge and therapeutic skillset within the interdisciplinary team, this cohort of 18 rehab professionals (OTs, PTs, and SLPs), were identified and education and training was provided on evaluation measures (JFK Coma Recovery Scale Revised) and therapeutic interventions. As this is an ongoing project, post implementation data will be collected and used to develop an objective and defined evidence-based training protocol for all subsequent treating clinicians that aligns with published best practice guidelines.
132 Evaluating Neuropsychological Outcomes and Balance in Retired Contact Sports Players With Post-Concussion Syndrome: An Initial Investigation
Camille Charlebois-Plante1,2; Samuel Guay1,2; Marie-Ève Bourassa1; Catherine Provost1; Marie-Louise Charette1; Raphaëlle Créniault1; François Prince1,3; Louis De Beaumont1,3
1Département de psychologie, Université De Montréal, Montréal, Canada; 2Centre de recherche du CIUSSS du Nord-de-l’Île de Montréal (Hôpital du Sacré-Coeur), Montréal, Canada; 3Département de Chirurgie, faculté de médecine, Université de Montréal, Montréal, Canada
Background
The impact of post-concussion syndrome (PCS) on cognitive and motor abilities in ex-contact sports players is increasingly recognized. Research has predominantly focused on elite athletes, leaving a gap in understanding PCS’s functional effects in the general population.
Objective
Our research aimed to thoroughly examine neuropsychological outcomes and balance control in ex-athletes from non-professional backgrounds, with a focus on the enduring consequences of PCS symptoms.
Methods
We conducted an extensive neuropsychological assessment to evaluate cognitive functions and utilized a dual force plate system to measure center-of-pressure (COP) displacement and velocity, considering age and education as covariates.
Results
Participants with PCS showed notable impairments in visual-spatial skills, immediate memory, and episodic memory. Regarding balance, no significant differences were observed in basic stances between the groups. However, under more challenging conditions, such as on uneven surfaces or during cognitive multitasking, the PCS group exhibited significant instability. This was particularly evident in medio-lateral balance during proprioceptive tests and in conditions of sensory limitation.
Conclusion
This study sheds light on the complex challenges former athletes with PCS encounter. The interaction between cognitive function and balance control, especially in demanding scenarios, highlights the necessity for individualized intervention strategies. These insights lay the groundwork for further investigations into the underlying mechanisms and potential treatment options for PCS in former athletes.
Keywords
Post-concussion syndrome, neuropsychological outcomes, cognition, postural control, center-of-pressure, former contact sports athletes
133 Social Determinants of Health (SDOH) and Context in Initial Access, Symptom Report and Recovery Within Pediatric Mild Traumatic Brain Injury (mTBI) Care
Sydney Wing1; Phillip Rosenbaum1; Neil Bhathela2; Daniel Ignacio1; Joshua Caiquo1; Natalie Gavi1; Brad Barney3; Faustina France-Nkansah3; Christopher Giza1; Talin Babikian1
1UCLA Steve Tisch BrainSPORT Program, Los Angeles, United States; 2Atrium Health, Charlotte, United States; 3University of Utah, Salt Lake City, United States
There is growing awareness of the degree to which Social Determinants of Health (SDOH) – encapsulated by social identities and demographic variables – impact many aspects of healthcare outcomes, including concussion care and recovery, making it imperative to consider the impact on patients with historically marginalized gender, racial, linguistic, and ethnic identities. Using retrospective data collected from the Four Corners Youth Consortium, we examined the impact of SDOH variables (e.g., race, ethnicity, insurance type, gender, age, and special educational services) on time to presentation (initial clinic contact), reported time to recovery, and symptom report (parent and child Post-Concussion Symptom Inventory [PCSI]) using multiple logistic regression and Cox proportional hazard regression statistical models. Included participants (n = 702) represented a primarily White (68.3%), Non-Hispanic/Latinx (79.1%) sample that has access to insurance (82.3%) and does not receive special education (82.5%). Gender, neurodiversity (whether child receives special education services), race and insurance were significant predictors of symptom report and recovery. Female adolescents (b = 8.33, p < .001) and their parents (b = 6.57, p < .001) reported higher increases in overall post-injury symptoms, including greater changes in physical, cognitive, emotional and fatigue symptoms. Neurodiverse (b = 1.07), p < .02), and Non-White (bBIPOC = 0.75, bOther = 1.32; p < .05) children self-reported heightened symptoms of fatigue. Insured patients (HR = 1.5, p = .03) experienced faster recovery, while female participants (HR = 0.77, p = .025) experienced slower time to recovery. Findings demonstrate that varying marginalized identities carry a higher symptom burden following a concussion, potentially facing more challenges for recovery. These findings reflect how social experiences related to privilege and marginalized status can ameliorate or compound the course of concussion symptomatology and recovery.
134 Detecting Covert Consciousness in the Intensive Care Unit Using Functional Near-Infrared Spectroscopy
Karnig Kazazian1; Sergio Novi1; Androu Abdalmalak1; Loretta Norton2; Derek Debicki3; Adrian Owen4
1Western Institute Of Neuroscience, Western University, London, Canada; 2Department of Psychology, King’s University College at Western University, London, Canada; 3Department of Clinical Neurological Sciences, Western University, London, Canada; 4Depart of Physiology and Pharmacology, Western University, London, Canada
Introduction
The assessment of consciousness in patients who have sustained a severe brain injury in the intensive care unit (ICU) poses a significant challenge. Covert consciousness refers to a state where patients exhibit no overt signs of behavioral responsiveness, yet their brain activity – as indexed through functional neuroimaging - demonstrates preserved awareness and cognitive function. In the ICU setting, accurately identifying such cases is crucial for appropriate patient care and medical decision-making. Functional near-infrared spectroscopy (fNIRS) is a promising modality for measuring and mapping brain function, as it is portable and can be safely used at the bedside This study explores the feasibility of using fNIRS to detect covert consciousness in patients with acute brain injury in the ICU.
Methods
16 behaviorally unresponsive ICU patients with varying brain injury etiology were enrolled. Patients were asked to imagine playing a game of tennis while undergoing fNIRS monitoring. The fNIRS technique enables the measurement of cerebral hemodynamic changes associated with cognitive processes, providing a window into the neural activity underlying motor imagery. 24 age and sex-matched healthy controls were also enrolled. The fNIRS setup consisted of a 129-channel NIRScoutXP system. A channel was considered activated if there was a significant increase in oxyhemoglobin and a concurrent decrease in deoxyhemoglobin (p<0.05).
Results
Of the 16 patients tested, two demonstrated the ability to follow commands during the motor imagery task despite the absence of observable signs of behavioral consciousness. Analysis of the fNIRS data revealed distinct patterns of neural activation during the motor imagery task in both patients and healthy controls. These findings were supported by positive responses to a language comprehension task.
Discussion: This study highlights the capability and feasibility of fNIRS to detect convert consciousness in patients who appear behaviorally non-responsive in the ICU. The results underscore the need for more nuanced and sensitive approaches to consciousness assessment in critical care settings. Further research and validation of fNIRS as a tool for detecting covert consciousness could revolutionize our understanding of patient awareness in the ICU, impacting treatment decisions and enhancing patient care strategies.
135 The Role of Bilingualism in Story-Telling Performance in Adults With Mild Traumatic Brain Injury
Monserrath Diaz1; Lillian Thornock1; Alexa Ybarra1; Megan Morton1; Rocio Norman1
1University of Texas Health San Antonio, San Antonio, United States
Background
Communication skills, while often overlooked in the rehabilitation of adults with mild traumatic brain injury (mTBI) are critical to successful community reintegration and re-entry into society. Assessment of language is often challenging in mTBI due to the lack of available sensitive and specific published tools (Duff et al). Recently, the use of story-telling discourse assessment has been explored in mTBI (Norman et al, 2020) but there is limited research on the expected performance of adults who speak a second language. In the US in particular, it is critical for clinical providers to understand the role of second language proficiency in order to accurately assess patients and plan treatment.
Methods
A main concept analysis (MCA) was implemented on “Cinderella” story re-tell samples of thirty-six participants with mTBI to quantify the accuracy and completeness of the story-telling using a well-validated task. The participants were divided into three groups (individuals who learned Spanish before the critical age of seven; individuals who learned Spanish after seven years; individuals who consider themselves monolingual). Relevant concepts based on the story were identified and scaled according to a coding system. Participants were assigned codes based on if key concepts of the story were included in their story-telling discourse and the level of accuracy in their performance.
Results
The final sample included 20 individuals who identified as bilingual before age age seven, seven bilingual individuals who identified as bilingual after age seven and eight monolingual individuals. Preliminary analyses indicated that mean MCA scores for the individuals who identified as bilingual before age seven outperformed the sequential and monolingual individuals, however, statistical significance was not reached. Further linguistic and grammatical analyses are underway to determine if differences at the microlinguistic level exist.
Discussion
The precise measurement of language performance after mTBI is currently elusive, as traditional language tests fail to sufficiently capture linguistic changes specific to mTBI. For individuals who speak one or more languages, assessment is further complicated however, this study is a first step in understanding these differences which in turn can help refine and optimize rehabilitation approaches for individuals from a variety of cultural and language backgrounds.
136 TET3 Activator Ascorbate Mitigates Motor and Cognitive Deficits Following Controlled Cortical Impact Brain Injury in Mice
Raghu Vemuganti1
1University of Wisconsin-Madison, Madison, United States
Ten eleven translocases (TETs) mediate the conversion of 5-hydroxymethyl cytosine (5-mC) to 5-hydroxymethyl cytosine (5-hmC). The TET3 isoform and 5hmC are known to be enriched in the neurons in brain. TET3 is known to promote cell survival by inducing the expression of anti-inflammatory genes. Vitamin C (ascorbate) is a potent activator of TET3. Hence, we tested the efficacy of ascorbate in curtailing secondary brain damage and promoting motor and cognitive functional recovery after traumatic brain injury (TBI) induced in adult C57BL/6 mice by controlled cortical impact (CCI). Mice were given 3 doses of 500 mg/Kg ascorbate i.p. at 5 min, 1 day and 2 days after CCI injury (n =7/cohort). Seven saline treated mice were used as control. Both cohorts of mice were subjected to motor function analysis by rotarod test (between days 5 and 28) and cognitive function analysis (between days 21 and 23) after the injury. Mice were pretrained for 3 days before each test. Mice were euthanized on day 21 and the cortical injury (lesion) volume was estimated using cresyl violet stained serial brain sections. Post-TBI motor dysfunction was significantly reduced in the ascorbate-treated cohort compared to vehicle control (p < 0.05 by 2-way repeated measures ANOVA with Sidak’s post hoc test). Ascorbate treated cohort stayed in the platform quadrant significantly longer than the vehicle control mice in the Morris water maze test (probe trial on day 24; p < 0.05 by Mann-Whitney U test). In addition, the cortical lesion volume was also significantly smaller in the ascorbate treated mice compared with the vehicle treated mice (p < 0.05 by Mann-Whitney U test). These results indicate that epigenetic modulation by ascorbate is promoter of better functional outcomes after TBI.
137 Acute Post-Concussion Changes in Oculomotor Function From Baseline: A Case Series
Jacqueline Theis1,2,3; Casey Batten4; Michael Silver2
1Virginia Neuro-optometry, Richmond, United States; 2University of California at Berkeley, Berkeley, United States; 3Uniformed Services University, School of Medicine, Bethesda, United States; 4Cedars-Sinai, Kerlan Jobe Institute, Los Angeles, United States
Background
Recent studies have shown that concussion may lead to clinical impairment of the oculomotor pathways, and this has led to increasing research in the clinical assessment of post-concussion oculomotor dysfunction and its roles in diagnosis and treatment of concussion.
Methods
All experimental procedures were approved by the Committee for the Protection of Human Subjects (CPHS), the defined Institutional Review Board (IRB) of University of California, Berkeley, and followed the tenets of the Declaration of Helsinki. Intercollegiate athletes at the University of California, Berkeley were asked to participate in an oculomotor assessment at baseline and after a concussion. All recruited athletes were clinically determined to be free from acute or subacute concussion at the time of the baseline examination by the team physician and diagnosed with a concussion by the same team physician. All post-concussion oculomotor assessments were evaluated 0-5 days post-injury (average of 2.55 days). All baseline and post-concussion eye examinations were conducted by the same optometrist and included a comprehensive clinical test battery to assess fixation, accommodation, vergence, saccades, smooth pursuits, versions, and vestibular-ocular reflex.
Results
A total of nine subjects (age 18-22 years; two female; seven male) were evaluated for this case series. Five of these subjects had a history of a previous concussion, with the number of previous concussions per subject ranging from 1-5, with an average of 2.0. Paired statistical comparisons of baseline versus post-concussion binary measures (fixation, saccades, pursuits, and versions) as well as nineteen continuous function variables (fusional vergence, near point of convergence, near point of accommodation, accommodative facility, and DEM subtest values) did not reveal statistically significant differences among the individual oculomotor metrics, possibly because of limited sensitivity due to the small sample size. When comparing the baseline data to clinical norms, seven of the nine subjects (77.8%) exhibited a pre-existing oculomotor abnormality. Of those seven, all had additional oculomotor abnormalities post-concussion when compared both to clinical norms as well as to their individual baseline assessments.
Conclusion
Changes in oculomotor function from baseline data following concussion in this case series provide clinical evidence in support of the hypothesis that concussive injury itself causes oculomotor dysfunction beyond possible pre-existing abnormalities. Without the baseline data in this case series, a number of these subjects would have been misdiagnosed post-concussion with symptoms that were based on pre-existing oculomotor abnormalities, and this could have delayed their return-to-play. Given increased use of oculomotor assessments in concussion diagnosis and management, this case series demonstrates the value of baseline assessments for increasing the accuracy and utility of oculomotor metrics in concussion management decisions.
138 Utilization of Computerized Dynamic Posturography Scores to Inform Rehabilitation Strategies in Dysfunctions of Postural Control
Victor Pedro1; Richard Lyon1; Diane Bienek1
1International Institute for the Brain, New York, United States
Introduction
Refractory postural instability is among the most challenging conditions, given the complex subsystems integrating into postural control. The rehabilitation of postural dysfunction relies on various assessments and treatment modalities, both low and high-tech, to address deficits in variably weighted sensory or motor subsystem inputs. Dynamic computerized posturography is a reliable, objective metric to assess postural stability in varying testing conditions. These scores are expressed as a percentage of the theoretical limit of stability. There needs to be more information regarding the use of computerized posturography to help direct interventions. This retrospective study aims to determine the efficacy of computerized posturography in informing therapeutic strategies. Specifically, in this cohort, the percentage stability score was used to help guide the rehabilitation mechanism (feedback, feedforward, or efferent copy), as well as the laterality of the treatment application to optimally engage the activity map of the cortico-cerebellar loops underlying motor planning.
Methods
The subject population with loss of postural control included migraine headaches (23.1%), post-concussion syndrome/traumatic brain injury (37.5%), dizziness/vertigo (21.2%), dysautonomia (2.9%), post-traumatic orthostatic tachycardic syndrome (2.9%), and other brain disorders (12.5%) as the primary diagnoses. The pre-treatment posturography stability scores were compared and the direction of head rotation with the greater stability score dictated the side of individualized Cortical Integrative Therapy (CIT) treatment. Post-treatment posturography stability scores were taken over the intervention course (mean = 3.77 weeks, range 1 day to 20.29 weeks). Analyses considered the laterality of treatment, pre- and post-treatment stability scores, and the primary diagnosis.
Results
The efficacy of the CIT treatment was indicated by over a 10% improvement (P < 0.001) in the mean post-treatment posturography stability score. Treatment ipsilateral to head rotation with the greater stability score produced near-equal results in all head positions. For example, the mean post-CIT treatment stability scores were comparable to the manufacturer’s normative data (CDP range of 69.8 to 74.9) for perturbed stability, eyes closed testing conditions. While improvement was observed with all primary diagnoses, the percent of control calculations (post-treatment score ÷ pre-treatment score X 100) indicated that patients with a primary diagnosis of dizziness/vertigo had the greatest improvement in stability scores (nearing 150% of control).
Conclusion
The stability score-informed intervention strategy, predicated on posturography results, optimized the efficiency of the motor planning loop. Based upon the level of compromise, the posturography stability scores can direct the laterality of treatment application in real-time. Further study of the use of dynamic posturography can identify its potential role in informing treatment strategies to improve the dysfunctional loop mechanisms.
139 Where Does Behavior Analysis Fit? Applying the Science of Behavior to All Aspects and Phases of Post-Acute Brain Injury Rehabilitation
Chris Schaub1; Marla Baltazar-Mars2; Paige Salinas1
1Collage Rehabilitation Partners, Paoli, United States; 2Collage Rehabilitation Partners-Learning Services, Lakewood, USA
Acquired brain injuries (ABI) can result in sequelae across multiple systems and domains that disrupt and impact the individual’s interactions with the environment, thus affecting behavioral relations. The term “neurobehavioral” is used to classify a wide array of challenging excesses and/or deficits of behavior resulting from ABI, that impact or impede an individual’s progress in rehabilitation and recovery and can ultimately pose safety concerns for the individual and caregivers. This presentation will include a discussion of how evidence-based, behavior analytic principles and practices can be applied at multiple levels of treatment, e.g. to address individual behaviors, in support of interdisciplinary collaboration, and to underpin case conceptualization. Two case studies will be presented to illustrate these areas of application and involvement, including data to highlight and support efficacy.
The first case study calls attention to the significance of the behavioral history of adults with ABI, which may include challenging behaviors pre-injury that can be exacerbated post-injury and complicate treatment planning and programming. The subject of this case study had a pre-injury history of physical and emotional trauma, as well as a diagnosis of borderline personality disorder, that required both inpatient and outpatient treatment. Following an ABI in their late twenties, resulting from a rollover car accident at high speed, pre-injury repertoires and sensitivities were profoundly disrupted, and at-risk behavior occurred at high levels across all dimensions and settings during rehabilitation. The principles and practices of behavior analysis helped to inform medication adjustments that proved instrumental in stabilization efforts and guided the acquisition and generalization of replacement behaviors that established readiness for access to the community and an eventual discharge to home.
The second case study will demonstrate how behavior analysis can play a less direct, but no less valuable role, in the rehabilitation process. A married, middle-aged individual with adult children, working in a management capacity at the time of injury, sustained an ABI in a pedestrian vs. motor vehicle accident. Efforts in acute and post-acute rehabilitation were significantly impacted by sequelae such as confusion, suspiciousness, paranoia and delusionality. This required management of non-reality-based behaviors and close monitoring of medical and behavioral stability, which in the post-acute phase included disrupted sleep, disorientation, irritability, at-risk wandering/mobility, etc. Throughout the rehab process, data collection and analysis supported medication considerations and adjustments. Eventually, following stabilization, behavior analytic input helped to guide systematic efforts to generalize behavior to the community and to establish readiness for a successful return home.
These case presentations represent programming and treatment efforts to address complex neurobehavioral sequelae in an intensive, residential, post-acute rehabilitation setting. Overall, key points of discussion will include data collection, challenging behaviors, specific treatment interventions to promote stabilization and readiness, interdisciplinary collaboration, and medication-related decisions.
140 Apply Knowledge Translation to Promote Rehabilitation Outcomes for People With Traumatic Brain Injury
Xinsheng Cindy Cai1
1Model System Knowledge Translation Center (MSKTC), Arlington, United States
Background
This presentation describes the knowledge translation approach that the Model Systems Knowledge Translation Center (MSKTC) and Traumatic Brain Injury Model System (TBIMS) researchers take to develop and disseminate user-friendly print and video resources to promote rehabilitation outcomes for people living traumatic brain injury (TBI). TBIMS centers provide clinical care and conduct research to improve the lives of people with TBI. The MSKTC supports TBIMS centers to conduct knowledge translation activities, identifies health information needs, and develops and disseminates information resources based on Model Systems research and available evidence. The MSKTC also collaborates with the Spinal Cord Injury Model System and Burn Injury Model System Programs to conduct similar knowledge translation activities. Both the MSKTC and the TBIMS are funded by the National Institute on Disability, Independent Living, and Rehabilitation Research, U.S. Department of Health and Human Services.
Methods
Knowledge translation is “the exchange, synthesis and ethically-sound application of knowledge—within a complex system of interactions among researchers and users—to accelerate the capture of the benefits of research” (Canadian Institutes of Health Research, n.d.). To maximize the impact of research and development activities to improve the lives of patients and families, it is important to engage stakeholders throughout the entire process (Barwick, Dubrowski, & Petrecca, 2020; Bowen, Botting, Graham, & Huebner, 2016; Nguyen et al., 2020; Parry, Salsberg & Macauley, 2015). The MSKTC collaborates with the TBIMS researchers to apply knowledge translation strategies and engage TBI survivors and their family members to develop, test, and disseminate free research-based resources.
Outcomes
The MSKTC has worked with the TBI model system researchers to develop resources on over 30 rehabilitation topics in multiple user-friendly formats such as factsheets, infocomics, videos, narrated slides, and podcasts. A MSKTC user feedback survey showed that 90.8% of the participants strongly agreed or agreed that MSKTC factsheets directly “apply to me or someone I know;” and 87.3% rated MSKTC factsheet quality as good or excellent. Between January 1, 2012 to October 31, 2023, over 5 million people from over 203 countries consumed the TBI contents on the MSKTC.org website. The MSKTC.org has been the go-to place for high quality rehabilitation resources for people living with TBI in the US and across the globe.
Conclusion
Knowledge translation can be an effective framework to help researchers better understand the needs of patients with TBI and families and develop strategies to meet their needs and improve their rehabilitation outcomes.
141 Escape Room: A TBI Case Based Interprofessional Study for OTD, DPT, and SLP Graduate Students
Rita Lenhardt1; Melissa Goodman1; Dianna Lunsford1; Andrew T. Caswell2
1Gannon University, Ruskin, United States; 2Gannon University, Erie, United States
We employed a mixed-method design (n=18) to investigate an innovative educational approach for allied healthcare professionals. The study centers around an escape room experience, where occupational therapy doctorate, doctor of physical therapy, and speech-language pathology graduate students collaboratively tackle a traumatic brain injury (TBI) case through puzzle-solving. The case was meticulously designed to address the knowledge required for interprofessional treatment of TBI. Puzzle scenarios encompassed assessments, impairments, and functional outcomes post-TBI, incorporating tools such as Rancho Los Amigos Levels of Cognitive Functioning Scale, Brunnstrom Stages of Stroke Recovery, Berg Balance Scale, aphasia symptoms, and patient management. Pre- and post-measures utilized the SPICE-R2 questionnaire, followed by structured focus group discussions. We averaged scores on the SPICE-R2 to create a full-scale composite, as well as composites for each of the three subscales for both the pre- and post-escape room surveys. We submitted the scores to a repeated measures t-test for each of the four pairs of composites and found significant increases in scores on four measures from pre-test to post-test, all ts < 3.20, all ps < .005. Qualitative analysis of narrative data obtained from focus group sessions unveiled two strong themes. Theme one: enjoyable educational approach. Participants expressed their enjoyment of the experimental learning format and this edutainment approach. Theme two: improved understanding of interdisciplinary contributions. This theme highlights the effectiveness of teamwork and the acquisition of insights into perspectives by other professions. The incorporation of case-based escape rooms as a pedagogical tool holds promise in enhancing the education of allied healthcare professionals, facilitating holistic comprehension of TBI management, and encouraging collaboration. Engaging in case-based activities during their training can potentially foster future interprofessional collaboration among healthcare practitioners. The long-term benefits to interprofessional cooperation are well documented and include favorable effects on patient outcome metrics, contentment with delivered healthcare services, and substantial cost reductions within the healthcare system. For a comprehensive evaluation of the long-term impact on knowledge acquisition related to TBI and interprofessional collaboration in clinical settings, further research in the form of a longitudinal study is warranted. This study holds potential in shaping future educational strategies in allied health professions, with applications in neurogenic disorders and beyond.
143 Treatment of Emotional Changes in an Infant With Traumatic Brain Injury: A Case Study
Theophilus Lazarus1; Gershom Lazarus1
1Emory University, Atlanta, United States
Following the motor vehicle accident, this two-and-a-half-year-old patient was rendered comatose, with a hospital admission GCS score of 8/15 and left frontal subdural hematoma associated with mild midline shift found on CT Brain Scan. Following conservative management and recovery from coma after 4 to 6 days, patient recovered from right-sided weakness but two years later displayed residual emotional and behavioral changes such as anger, regressed emotional attachment to his mother, indiscriminate aggression to familiar family members and social-emotional interaction problems. Patient underwent weekly sessions of family integration therapy with involvement of his mother initially, and with gradual introduction of his grandmother and thereafter his siblings into the therapeutic setting for a period of 12 months, using the Infant-Toddler Social and Emotional Assessment (ITSEA) as per-and post-treatment tool to assess changes. Patient’s emotional balance and behavioral control showed improvement within the family setting the stage on the ITSEA, This paper outlines the remediation of emotional and behavioral changes in a young TBI patient in a family setting.
144 Multidimensional Health Perceptions: Preliminary Reliabilities of a Measure and Initial Characterization Among Persons in the Traumatic Brain Injury Model Systems
Shannon Juengst1,2; Angelle Sander1,3; Monique Pappadis4; Dawn Neumann5; Amanda Rabinowitz6; Therese O’Neil-Pirozzi7; Librada Callender8
1TIRR Memorial Hermann, Houston, United States; 2UT Houston Health Sciences Center, Houston, United States; 3Baylor College of Medicine, Houston, United States; 4University of Texas Medical Branch, Galveston, United States; 5Indiana University, Indianapolis, United States; 6Moss Rehabilitation Research Institute, Elkins Park, United States; 7Spaulding Hospital, Boston, United States; 8Baylor Scott and White, Dallas, United States
Beliefs and perceptions about health can affect healthcare engagement, treatment adherence, and health outcomes. The Multidimensional Health Perceptions Questionnaire (MHPQ) was designed to assess: 1) health perceptions about the causes and consequences of health conditions; 2) the benefits and barriers to maintaining and improving health; 3) how to best accomplish health-related goals and control health circ*mstances; 4) the role of religion and/or spirituality in healthcare, perceived discrimination and its effects on care; 5) and trust in healthcare providers. Prior research in a mixed clinical and general population sample showed the MHPQ had a high content validity index of 98.1% and factor structure with seven domains. Items in seven health perceptions domains, or subscales, are averaged to produce a score ranging from 1 (low agreement) to 5 (high agreement). These subscales are: Anticipated Discrimination and Judgement, Spiritual Health Beliefs, Social and Emotional Well-being Beliefs, Confidence and Trust in Healthcare providers and Medicine, Health Self-Efficacy, Trust in Social Health Advice, and Health Literacy. The objectives of the current study are to validate the MHPQ among persons with traumatic brain injury (TBI) and characterize their health perceptions profiles to healthcare communication via a multisite study in five TBI Model Systems centers in the United States. Herein we present preliminary data from that study on the internal consistency of the MHPQ (English version) subscales, as well as descriptive characterization of these health perceptions domains among persons with chronic TBI. Forty-eight participants, at least one year after moderate-to-severe TBI, completed the MHPQ once (85.4% via electronic survey, 14.6% via telephone interview, with an average completion time of 9.2 minutes). Participants in the sample were 19-79 years old (mean=46.0) and were mostly men (64.6%), Non-Hispanic/Latino (85.4%), and White (64.6%). Internal consistent reliabilities (Cronbach’s α; >.70 considered “good”) and descriptive characterization of the domains [mean (M), standard deviation (SD), range (R)] were as follows: Anticipated Discrimination and Judgement (α=.90, M=2.1, SD=0.6, R=1.0-3.5); Spiritual Health Beliefs (α=.89, M=3.1, SD=0.8, R=1.2-4.6); Social and Emotional Well-being Beliefs (α=.79, M=3.5, SD=0.7, R=1.4-4.6); Confidence and Trust in Healthcare Providers and Medicine (α=.72, M=3.7, SD=0.4, R=3.1-5.0); Health Self-Efficacy (α=.75, M=3.9, SD=0.5, R=2.5-4.9); Trust in Social Health Advice (α=.83, M=2.8, SD=0.8, R=1.3-5.0); and Health Literacy (α=.86, M=4.1, SD=0.5, R=2.2-5.0). Findings support that the MHPQ has good to excellent internal consistency reliability across its subscales and that it captures a range of health perceptions in a relatively short amount of time. Understanding health perceptions of those with TBI is a critical first step towards personalizing communication and intervention approaches to be responsive to diverse individuals across cultures and populations. These findings can be used to provide healthcare professionals with information that can guide communications with people with TBI to be more personalized and culturally humble.
145 Red Eye: Concurrent Etiologies in a Patient With Moderately Severe Traumatic Brain Injury
Alex Rose1; Michelle Andary1; Stuart Yablon1
1Mary Free Bed Rehabilitation Hospital, Grand Rapids, United States
A 47-year-old male presented to acute inpatient rehabilitation with a moderately severe traumatic brain injury (TBI) 12 days after falling off a retaining wall. Initial neuroimaging demonstrated extensive orbitofrontal and bitemporal hemorrhagic contusions, and intraventricular hemorrhage. Other injuries included skull fracture and T12 compression fracture with resulting severe headache, back pain, right sided hearing loss, and vision problems. Physical examination was remarkable for bilateral chemosis and injected sclera. Pupils were equal, round, and reactive to light with accommodation. Extraocular movements displayed impaired lateral and dysconjugate gaze bilaterally. There was right facial weakness with injection of the right eye. Accordingly, neuro-ophthalmology was consulted. On ocular examination, a corneal ulcer was demonstrated in the right eye. After pupillary dilation, photo-retinography demonstrated impressive papilledema. RI/MRV of the brain revealed impressive bilateral temporal and frontal hemorrhagic contusions with no evidence of sinus thrombosis. The patient eventually recovered after symptomatic treatment.
146 Dimensions of Participation as Predictors of Satisfaction with Roles and Abilities after Traumatic Brain Injury: A TBI Model Systems Study
Amanda Wisinger1; Robiann Broomfield1,2; Shannon Juengst1; Angelle Sander1,2; Mark Sherer1,2
1TIRR Memorial Hermann, Houston, United States; 2Baylor College of Medicine, Houston, United States
Background/Rationale
Participation refers to involvement in meaningful social roles, such as work or school, relationships, and leisure activities. Moderate to severe traumatic brain injury (TBI) is known to affect frequency of participation in these activities. However, participation frequency is not always equivalent to participation satisfaction. A better understanding of meaningful participation that reflects a person’s abilities and values may aid in identifying better targets for rehabilitation after TBI.
Main Objective
To determine the contribution of various dimensions of participation to satisfaction with social roles and abilities in a sample of individuals with complicated mild to severe TBI.
Methods
(including design, setting, sample/patient characteristics, and measures): Secondary analysis of baseline data from participants enrolled in a longitudinal intervention trial. We used data from 127 participants [mean age=35.24; 64.6%; predominately female (64.6%) and non-Hispanic White (70.1%)] who had completed a demographic questionnaire, portions of the TBI Quality of Life Scale (TBI-QOL), and the Participation Assessment with Recombined Tools-Objective (PART-O). Results: We performed a hierarchical regression to predict satisfaction with social roles and abilities using different dimensions of participation including objective (PART-O Out-and-About, Social Relations, and Productivity scores) and subjective (TBI-QOL Ability to participate in social roles and activities, Independence, and Stigma) dimensions. PART-O scores explained 17% of the variance [R2change=.17, p<.001] in satisfaction with social roles and abilities. Ability to participate in social roles and activities and Independence explained 40% of additional variance [R2change =.40, p<.001] in satisfaction with roles and abilities. Stigma explained an additional 2.3% of the variance [R2change =.023, p=.01].
Conclusions/Future Implications
How one perceives their abilities to participate and be independent, rather than the objective frequency of participation, accounted for a larger portion of the variance in how satisfied one was with their ability to participate in social roles and activities. Investigating different dimensions of participation in this population, rather than simply frequency, may result in more meaningful participation in this population.
147 Return to Driving following Moderate-to-Severe Traumatic Brain Injury: A Longitudinal Multi-Center Investigation
Thomas Novack1; Yue Zhang1; Jennifer Marwitz1; Thomas Bergquist2; Charles Bombardier3; Richard Kennedy1; Lisa Rapport4; Candice Tefertiller5; Thomas Watanabe6; William Walker7; Robert Brunner1
1University of Alabama at Birmingham, Birmingham, United States; 2Mayo Clinic, Rochester, United States; 3University of Washington, Seattle, United States; 4Wayne State University, Detroit, United States; 5Craig Hospital, Englewood, United States; 6Moss Rehabilitation Research Institute, Elkins Park, United States; 7Virginia Commonwealth University, Richmond, United States
Objective
To determine rates of return to driving following traumatic brain injury (TBI) and explore driving patterns and crash rates pre- and post-injury.
Method
Adults (N = 334) with moderate-to-severe TBI enrolled by eight TBI Model System sites. A driving survey was completed during inpatient rehabilitation (for pre-injury information) and at one- and two-years post-injury.
Results
Rates of return to driving were 65% at one-year follow-up and 70% at two-year follow-up. Return to driving was associated with higher levels of family income. Frequency of driving and distance driven were diminished compared to pre-injury as was frequency of driving in risky conditions (heavy traffic, bad weather, at night). Crash rates were 14.9% in the year prior to injury (excluding the crash that resulted in TBI), 9.9% in the first year post-injury, and 6% during the second year post-injury. Post-injury, the odds of a participant having at least one crash was decreased by 40% (95% CI: 15% - 59%) per year (p=0.005). Amongst participants who endorsed crashes in the year prior to their injury, the average number of crashes reported was 1.57 (77 crashes reported by 49 participants). At follow-up, these averages were 1.50 for the 1-year follow-up (i.e., 18 crashes for 12 participants) and 1.33 for the 2-year follow-up (i.e., 12 crashes by 9 participants). Logistic regression examining those who did or did not experience a crash did not reveal any significant findings for Year One. At Year Two the only significant finding was for participants’ time to follow commands. Those with milder injuries were more likely to experience a crash.
Conclusion
Consistent with prior reports, this investigation has shown that return to driving is a common occurrence following TBI, although individuals may limit their driving in terms of frequency of driving or total distances driven compared to pre-injury. Also, restriction of driving in particular situations is common. Incidence of crashes in this population is shown to be higher than population-based statistics, but this investigation highlights the critical importance of considering the possibility that, as a group, individuals who sustain a TBI are at higher risk of crash even prior to their injury. Discussion of crash risk needs to be tempered by the finding that 85% of those who returned to driving after injury did not report experiencing any crashes during follow-up interviews. Future work is needed to identify both premorbid and post-injury characteristics that may influence likelihood for adverse events while driving. Such studies will assist in development of screening tools and appropriate regulations to promote appropriate return to driving following TBI.
148 Postural Orthostatic Tachycardia Syndrome (POTS): Transcranial Magnetic Stimulation (TMS) as a Therapeutic Option.
Ananth Karanam1; Rueshil Fadia1; Ingrid Contreras1; Ameer Chaudry1; Ahmed Marabeh1; Mohammed Ahmed1
1Kaizen Brain Center, La Jolla, United States
Background
Postural orthostatic tachycardia syndrome (POTS) is a disorder of the autonomic nervous system which results in lightheadedness following a postural change from supine to standing upright and an associated rapid rise in heart rate. Other symptoms include physical and mental fatigue, exercise intolerance, anxiety, blurry vision, and headaches. POTS symptoms are often difficult to manage, as limited treatment options exist. Transcranial magnetic stimulation (TMS) is an FDA-approved treatment for depression and anxiety. We hypothesize that by addressing the anxiety symptoms of the POTS spectrum with TMS, other POTS symptoms may improve.
Methods
Two patients with POTS underwent TMS treatment at Kaizen Brain Center. One received Kaizen’s Accelerated TMS (KATMS) protocol (ten, 1800-pulse iTBS sessions daily; 45-minute interval between sessions) for five consecutive days and the other received the regular POTS TMS protocol (one, 1800-pulse iTBS session daily) for thirty-five consecutive weekdays. Resting state fMRI (RS-fMRI) was used to individually target the region of the amygdala most associated with anxiety in each patient. Treatment was administered at each patient’s unique resting motor threshold. HRV, heart rate, cognitive fatigue, depression, and anxiety were measured and monitored using questionnaires and electronic devices at baseline, throughout treatment, and post-treatment.
Results
Two weeks post-treatment, the patient that received KATMS experienced a 20% decrease in anxiety (measured during a follow-up visit), a 10-point increase in HRV (measured using the Elite HRV App), and a 7.5% improvement in orthostatic intolerance (measured by the NASA-10 Lean Test). This patient will continue to be monitored. The patient receiving the regular POTS TMS protocol is four weeks into treatment and has already experienced a 13% improvement in orthostatic intolerance (measured by the NASA-10 Lean Test), as well as increased physical stamina and a rejuvenated appetite. Additional data will become available throughout this patient’s treatment and follow-ups.
Conclusion
TMS has shown some promise in addressing POTS symptoms.
149 Pattern of Functional and Somatic Symptoms and Symptoms of Illness Anxiety After Recent and Remote Mild Head Injuries
Mohamed Gheis1
1University Of British Columbia, Victoria, Canada
Background
Functional Neurological Disorder (FND), Somatic Symptom Disorder (SSD) and Illness Anxiety Disorder are the main categories of Somatic Symptom and related conditions of the DSM 5. These conditions are recognized to occur following head trauma. Psychological factors associated with these conditions are thought to play a role in perpetuating some complications of mild head injury. The role of sensitizing physical events, such as trauma, is also thought to affect emerging psychopathologies of functional and somatic symptoms.
Objectives
To evaluate potential differences in the pattern of functional and somatic symptoms and symptoms of illness anxiety in patients with mild head trauma in comparison to patients with the primary diagnosis of FND, SSD and illness anxiety disorder.
To explore whether any potential differences are related to the duration of the diagnosis.
Methods
This is a retrospective data analysis of thirty-four patients with FND-SSD and illness anxiety disorder consecutively referred to a specialist neuropsychiatric service. The patients’ somatic scales and subscales of the Personality Assessment Inventory (PAI) were analyzed and compared against a control sample of patients with FND-SSD without head trauma. These scale-subscales include overall somatic symptoms, somatization, conversion, and health concerns. The results were subsequently stratified based on the duration of the illness.
Results
There was a statistically significant difference specifically in the conversion subscale between the groups with and without head trauma, with a mean Conversion T Score of 66 in the former and 84 in the latter (p=0.012), denoting less severe conversion processes post-head trauma but equally severe somatization and illness anxiety pathologies in patients with and without head injuries. Patients with post-trauma diagnosis tended to have a mean duration of illness approximately four years shorter than patients with FND-SSD-illness anxiety without head trauma. We were not able to establish a statistically significant association between the duration of illness and the pattern of symptoms in patients with or without head trauma. The difference between the two groups may be related to the nature of psychopathological processes rather than duration.
Conclusions: Patients with post-head injury FND-SSD may have some unique psychopathological and symptomatologic presentations of their SSD and related conditions.
151 Prevalence & Psychosocial Dysfunction in Community-Based Survivors of Traumatic Brain Injury Over Three Decades: A Randomized and Representative California Sample
Daniel Ignacio1,2,3; Talin Babikian2; Charles Degeneffe1,4; Todd Higgins1,5
1Department of Rehabilitation TBI Advisory Board: Data Analytics Committee, Sacramento, United States; 2Steve Tisch UCLA BrainSPORT Program, Los Angeles, United States; 3St. Jude’s Brain Injury Network: HI-CARES, Fullerton, United States; 4San Diego State University, San Diego, United States; 5Disability Rights California, Sacramento, United States
Rates of traumatic brain injury (TBI) have traditionally relied on medical incidences to estimate prevalence. However, issues related to reporting and accessing medical care (e.g., unaware, uninsured, undocumented; Rao et al., 2020), charting medical encounters (e.g., unspecified head injury S09; Peterson et al., 2020), and diagnosis/definition (Patricios et al., 2023; Silverberg et al., 2023), have raised questions regarding the true prevalence of TBI in the community. Moreover, there have been organized efforts to move away from simple tripartite classification of TBI as mild, moderate, or severe to incorporating other severity indicators and risk stratification by outcome.
The present retrospective cohort study is an community-based surveillance methods that utilized three probability-based sampling methods for recruitment using a combination of mixed-mode random probability selection method using the United States Postal Service Delivery Sequence File (geographically stratified by population density; n = 25,000), Computer Assisted Telephone Interviewing technology (65% mobile/cellular; n = 15,000), random digit-dialing telephone recruitment of Californian participants (n = 10,000) of the National Behavioral Risk Factor Surveillance Survey, and quota-based recruitment method using registered California voter demographics.
In the total sample of California residents (N = 1,052), 42% self-endorsed a history of at least one event of any head/neck injury (M = 3.89, SD = 10.07), with 25% endorsing an associated period of lost consciousness (15% of sample). An average of three decades (M = 30.4, SD = 16.2) had elapsed since initial head trauma for the present sample, which were then compared on self-endorsem*nts of cognitive, physical, and social dysfunction to the general California subgroup without head injury.
Ordinary least squared models were used to regress endorsem*nts of employment difficulties, justice system involvements, and experiences with marginalized housing on endorsem*nts of persistent depressive symptoms, generalized anxiety symptoms, neurocognitive disturbances, frequency of intoxication, presence of psychosis, and physical difficulties (e.g., ADLs) after controlling for age, gender, years of education, and income. All models significantly predicted the psychosocial outcome of interest with the head trauma estimates consistently ranking as a top predictor right next to frequency of intoxication for experiences with marginalized housing, presence of psychosis for justice system involvements, and difficulties with independently completing ADLs for employment difficulties. These findings provide initial evidence that suggests that complications associated with TBI manifest, over decades, as psychosocial dysfunction in a disease-like fashion. This may have a number of direct and indirect explanations, which in addition to a biological TBI signature, include lack of needed environmental supports (e.g., HCBS Medicaid) to manage cognitive and affective symptoms that may be ancillary to a brain injury, unfortunate community messaging (e.g., media, poor acute/post-acute medical management of symptoms and attributions), or inaccurate education about appropriate expectations and health-risk behaviors to enhance successful community reintegration following TBI.
152 Are the Symptoms of Peripartum Depression a Consequence of Undiagnosed Brain Injury From Intimate Partner Violence?
Rachel Plouse1,5; Jessica Almgren-Bell2,5; Nicolette McNair1,5; Elsa Nico3,5; Grayson Elliott4,5; Brooklyn Copeland5; Zofia Lowy5; Edie Zusman5,6; Erica Montes5,7
1Touro University Nevada College of Osteopathic Medicine, Henderson, United States; 2Northwestern University, Chicago, United States; 3University of Illinois College of Medicine at Chicago, Chicago, United States; 4Watauga High School, Boone, United States; 5Safe Living Space, Moraga, United States; 6Neuroscience Partners, Moraga, United States; 7Deborah Wilson MD and Associates Gynecology, Scottsdale, United States
Introduction
Homicide is one of the leading causes of maternal mortality in the U.S. and approximately half of these deaths are associated with domestic and intimate partner violence (DV/IPV). With medical advances, maternal obstetric complications have declined in recent years, however maternal mortality continues to increase in part due to violence. Research has shown that DV/IPV increases in both incidence and severity during pregnancy. Understanding that 74% of individual DV/IPV events include injury to the head and neck, including strangulation, it is likely that many women sustain peripartum concussions and abuse induced brain injuries (AIBI). Abuse induced brain Injury often presents with a depressed mood, difficulty concentrating, sleep problems, emotional lability, and/or fatigue, similar to the presentation of peripartum depression (PPD). Given the similarity of clinical symptomatology, are a subset of women with PPD actually suffering from an AIBI? In this review, we explore the association between peripartum depression, domestic violence, and brain injury.
Methods
A PubMed search was performed from January 2016, the publication date of the U.S. Preventive Services Task Force Recommendation for postpartum depression screening, to July 2022 for keywords prenatal, peripartum, or postpartum depression combined with domestic and/or intimate partner violence. 120 articles met criteria for review to assess available prevalence data and associations between PPD and DV.
Results
The mean prevalence of prenatal, peripartum, and postpartum depression was 25.0%, 17.7%, and 21.1% respectively, with an overall average of 23.5% and range of 5.8-50.5% across all groups. An average of 19.6% women experienced DV/IPV during pregnancy. Of the 98 papers that commented on DV/IPV, 73 (74.5%) found that DV/IPV was strongly associated with PPD. No papers commented on head injury, brain injury, or concussion surrounding pregnancy.
Conclusion
Our results show that approximately one in five women experience DV/IPV during pregnancy. While 74% of DV/IPV victims report head injury, to date, no studies have investigated DV/IPV-associated brain injury during the peri- or post-partum period. Given the significant similarities between AIBI and PPD symptoms, there is a critical need for research on the prevalence of peripartum abuse induced brain injury potentially including screening for peripartum brain injury with the current practice of peripartum depression assessment.
153 Corpus Callosum (CC) Integrity and Associated Neurocognitive Functions After Pediatric Brain Injury
Daniel Ignacio1,2; K. C. Bickart1,5; E. L. Dennis3; Aliyah Snyder4; Robert Asarnow5; Christopher Giza1,5; Anne Brown1; Talin Babikian1,5
1Steve Tisch UCLA BrainSPORT Program, Fullerton, United States; 2St. Jude Brain Injury Network: HI-CARES, Fullerton, United States; 3University of Utah, Salt Lake City, United States; 4University of Florida, Gainesville, United States; 5UCLA Health, Los Angeles, United States
Moderate/Severe Traumatic brain injury (msTBI) often results in diffuse injury to white matter (WM), particularly to the corpus callosum (CC) (Dennis et al., 2015). Linking this CC vulnerability to cognitive outcomes has been more difficult given that CC function has been understudied and cognitive outcomes following msTBI are heterogeneous. This is an especially important problem for younger patients whose brains are in a period of ongoing rapid development. One indicator of CC function, which may mediate a link between CC structural integrity and cognitive outcomes, is interhemispheric transfer time (IHTT) (Ellis et al., 2016). Within pediatric msTBI samples, a bimodal distribution in IHTT exists, revealing a subgroup of children with either IHTT times comparable to healthy controls or significantly slower (Dennis et al., 2017). The IHTT subgroups demonstrate divergent trajectories of CC structural recovery as measured by Mean Diffusivity (MD) in the CC, an index of structural integrity measured by Diffusion Tensor Imaging (DTI). Both slow and normal IHTT subgroups showed worse MD in the CC in the post-acute timeframe after msTBI, but only the normal IHTT subgroup normalized MD in the CC at the chronic timeframe. Although in that study, IHTT subgroups did not differ on a broad index of cognitive functioning, another study showed that slow IHTT predicted worse cognitive outcomes post-acutely in pediatric msTBI (Moran et al., 2016). In this study, we aimed to reconcile these findings by testing whether IHTT could predict not only divergent MD recovery trajectories after pediatric msTBI but also more discrete cognitive outcomes.
In this study, 34 survivors of pediatric msTBI were compared to 45 well-matched controls (e.g., community members, uninjured siblings) on measures of IHTT, DTI, and standardized neurocognitive tasks of working memory. The sample was evaluated as early as one month (M = 4.18, SD = 2.24) following msTBI (baseline) and re-evaluated as far out as 24 months (M = 17.16, SD = 2.34). ANCOVA models with years of parental education, age, and gender as covariates revealed that trajectories (interaction) of structural WM improvement versus disorganization in CC projections (i.e., frontal, temporal, parietal), as measured by MD, matched the working memory scaled scores (age-adjusted) of the subgroups, F (2, 70) = 3.22, p = .046, ηp2 = .084. Neurocognitive and brain imaging biomarkers as stratified by an IHTT biomarker collected at an early stage of recovery post-msTBI resemble one another at baseline and one-year follow-up, suggesting that significantly higher MD is consistently associated with significantly poorer letter number sequencing at both time points for Slow IHTT, but not Normal IHTT. Future research will assess associations with adaptive behaviors, family factors, and functional outcomes to potentially identify which children may need more environmental/community support following msTBI in service toward successful reintegration.
154 Improving Post-TBI Participation: The Community-Based Neuropsychological Rehabilitation Approach
Yingying Liu1; Daniel Ignacio1; Elvina Chow1; Ren Mizuhara1; Samandeep Mankatala1; Phu Uong1
1St Jude Brain Injury Network HI-CARES, Fullerton, United States
Introduction
Reduction in participation in various activities (e.g., social, household) is a common functional outcome of traumatic brain injury (TBI) and is associated with lower quality of life (Goverover et al., 2017). The Community-Based Neuropsychological Rehabilitation (CBNPR) Model (Judd & DeBoard, 2009) emphasizes the importance of not only addressing individual deficits but also facilitating socio-environmental changes to improve the participation of individuals with neurological conditions during neuropsychological rehabilitation (NPR). Existing studies examined the effects of individual factors (e.g., mental health, pain, cognition) and socio-environmental factors on post-TBI participation separately (Kersey et al., 2020); research that investigates the interaction between the two is needed.
Objectives
the present study aims to 1) determine the effect of Insurance Provider on post-TBI Participation; and 2) examine the interaction effect between Insurance Provider, Depression, Anxiety, Physical Difficulties, and Neurocognitive Symptoms on Participation.
Methods
CATBI registration packets that include relevant symptoms checklists, Mayo-Portland Adaptability Inventory Participation Index (M2PI), and Community Integration Questionnaire (CIQ) were collected from 229 survivors with TBI between 20 to 89 years old (M = 50.87, SD = 15.46). The participation of participants with Medicaid, Medicare, Medi/Medi, Commercial/Employer-provided/Private insurance was examined by a one-way MANOVA. A one-way MANCOVA was conducted to test the interaction effect of Insurance Provider, Depression, Anxiety, Physical Difficulties, and Neurocognitive Symptoms on Participation.
Results
The combined Participations (i.e., M2PI and CIQ) of survivors with different Insurance Providers were significantly different (p < .05). Participants with Commercial/Employer-provided/Private insurance scored significantly lower on M2PI than participants with Medicare and Medi/Medi. There was a statistically significant five-term interaction between Insurance Provider, Depression, Anxiety, Physical Difficulties, Neurocognitive Symptoms (p < .001). However, after controlling for the covariates, the only significant difference lies between the CIQ scores of individuals with Medi/Medi and Commercial/Employer-Provided/Private insurance.
Conclusion
The significant five-term interaction between Insurance Provider, Depression, Anxiety, Physical Difficulties, and Neurocognitive symptoms supports the CBNPR model in terms of incorporating both individual-health and environmental factors to promote participation post TBI. The present study underscores the pivotal role of insurance providers in shaping post-TBI participation outcomes. Notably, participants covered by Commercial/Employer-provided/Private insurance experienced less perceived obstacles for participation. Insurance transformation, such as Enhanced Care Management, that extends beyond traditional healthcare to include community-based resources could facilitate the reintegration process following TBI. Future research should also investigate other socio-environmental factors to better understand their interaction with individual-health factors. The findings also highlight the need to incorporate physical, mental, and cognitive health support (e.g., by resource facilitation) in NPR to promote participation of individuals with disadvantaged socioeconomic status and disabling conditions.
155 Framing Racial Disparities within Mild Traumatic Brain Injury from an Ecological Systems Perspective: A Systematic Literature Review of Risk Factors for Black Athletes
Sydney Wing1; Joshua Caiquo1; Chanté Butler2; Talin Babikian1
1UCLA Steve Tisch BrainSPORT Program, Los Angeles, United States; 2Medical College of Wisconsin, Milwaukee, United States
There is an apparent phenomenon where Black adult and pediatric athletes face disparities within their care, treatment, and recovery from mild traumatic brain injury (mTBI), or concussion while playing their sport. Previous literature has demonstrated that Black athletes who have experienced sports-related concussions (SRC) are less likely to receive formal concussion diagnoses, and subsequent referrals to tertiary concussion care. Additionally, Black athletes have demonstrated lowered access to clinical care, concussion knowledge and symptom identification, as well as intention to report injury and overall poorer psychosocial outcomes following injury. Overall, the current body of literature has identified that race is a salient social determinant of health for general mTBI and SRC – the axis of privilege and marginalization associated with race, can impact presentation for care, receiving diagnoses, symptom reporting and tracking, and the process of recovery or return to baseline functioning. However, these empirical findings do not elucidate why nor how these various factors compound. Thus, there is a need for a framework to conceptualize and create a clear theory for how these factors compound. Particularly, there is a need to encapsulate how sociocultural experiences of power, access, and biases can impact Black athletes experiencing mTBI. The authors use Ecological Systems Theory (EST; Bronfenbrenner, 1979) to create a novel organization-systems model of identified findings and theory that demonstrate and support racial disparities within general mTBI and SRC. A comprehensive literature search was employed to identify recent (published ≤10 years) empirical studies and theoretical perspectives on racial disparities in mTBI for Black patients and athletes. Using EST as a framework, the literature review examines and organizes these findings within the context of (1) historical and sociopolitical events and systems, (2) sociocultural ideologies and policy, (3) indirect and (4) direct community and cultural factors, as well as (5) person-centered social experiences and identities (social determinants of health). Ultimately, the organizational structure provides a clear thread on how macro-level policy and perceptions, can impact micro-level clinical care and decision-making for Black athletes and their experiences with mTBI.
156 Restoring Efficient Sleep After TBI: A Randomized Controlled Trial of a Guided Computerized CBT-I Intervention
Molly Sullan2; Lisa Brenner1; Adam Kinney1,2; Kelly Stearns-Yoder2; Daniel Reis2; Emerald Saldyt2; Jeri Forster2; Nazanin Bahraini2
1University of Colorado, Aurora, United States; 2Department of Veterans Affairs, Rocky Mountain MIRECC, Aurora, United States
Background
Individuals with a history of moderate-severe traumatic brain injury (TBI) experience a significantly higher prevalence of sleep-related problems including insomnia compared to members of the general population. While individuals living with TBI have been shown to benefit from traditional insomnia interventions (e.g., face-to-face [F2F]), such as Cognitive Behavioral Therapy for Insomnia (CBT-I), multiple barriers exist (e.g., cost, insufficient numbers of adequately trained healthcare providers, limited transportation, patient perceptions) that limit access to such F2F evidence-based treatments. Although computerized CBT-I (CCBT-I) has been shown to be efficacious in terms of reducing insomnia symptoms, individuals with moderate-severe TBI may require support to engage in such treatment.
Methods
This is an RCT of a guided CCBT-I intervention for individuals with a history of moderate-severe TBI and insomnia. The primary outcome is self-reported insomnia severity, pre- to post-intervention. Exploratory outcomes include changes in sleep misperception following CCBT-I and describing the nature of guidance needed by the Study Clinician during the intervention.
Results
Data collection is underway, with a notable number of individuals already having completed the trial. With the grant ending (Spring 2024) it is expected that sufficient data will be collected to present feasibility/acceptability data, as well as initial outcome findings.
Conclusion
This study represents an innovative approach to facilitating broader engagement with an accessible and readily available no-cost evidence-based online treatment for insomnia among those with a history of moderate-severe TBI. Findings will provide evidence for the level and nature of support needed to implement guided CCBT-I. Moreover, should results suggest efficacy, this study would provide support for a strategy by which to deliver guided CCBT-I (with support) to individuals with a history of moderate-severe TBI.
157 Investigating Seasonal Affective Disorder in a Population With Traumatic Brain Injury From the Ottawa Vista Centre for Brain Injury Services Using the SPAQ
Justine Tubin1
1Ottawa Vista Centre Brain Injury Services/University of Ottawa, Ottawa, Canada
Up to 40% of patients will suffer from 2 or more psychiatric disorders following traumatic brain injury (TBI)6. A positive correlation between Axis-1 affective disorders, such as major depressive disorder (MDD) and TBI has been identified by a growing amount of literature1. Seasonal affective disorder (SAD) is characterized in the DSM-V as a subtype of MDD, including at least 2 episodes of MDD in the last 2 years demonstrating evident seasonal variability and is marked by full remission at the end of the season (mostly associated with winter)2. However, there’s limited data investigating the relationship between TBI and SAD. Interestingly, proposed mechanisms for the pathophysiology of both SAD and TBI involve dysregulation of serotonergic pathways in the CNS3. Studies have shown that patients with SAD have an upregulation of SERT in the winter compared to healthy controls, causing less available 5-HT in the synaptic cleft and TBI has been associated with as much as a 17% loss of serotonergic neurons4,8,9. Using the Seasonal Pattern Assessment Questionnaire (SPAQ), a widely used screening tool for SAD, this study aims to determine if there is a significant difference in the results of the questionnaire in a population with TBI from the Ottawa Vista Centre for Brain Injury Services compared to a control group5. More specifically, we will be comparing the mean Global Seasonality Score (GSS) between the groups using ANOVA as well as the number of positive screens for SAD in each group. A positive screen for SAD is a GSS of 11 or greater with a score of “moderate” or higher on question 17 of the SPAQ7. Exclusion criteria include actively taking anti-depressants as well as ETOH abuse3. The control group consists of students at the University of Ottawa who volunteered to fill out the SPAQ. We hope the results of this study will help direct best practice guidelines in caring for people post-TBI by helping to understand what cognitive and psychiatric illnesses can impact their independent functioning by acting as a barrier to reintegration into the community.
158 Evolving Practices: 2023 Updates to Pediatric Concussion Care
Jennifer Dawson1; Nick Reed2; Andree-Anne Ledoux1,3; Roger Zemek1,3
1Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada; 2University of Toronto, Toronto, Canada; 3University of Ottawa, Ottawa, Canada
Clinical guideline recommendations for pediatric post-concussion care and management have undergone major updates in 2023. The Living Guideline team includes 48 concussion clinical experts, researchers, and individuals with lived experience from across the US and Canada. This team collaborates on the Living Guideline for Pediatric Concussion Care (PedsConcussion) project to review new evidence and update the 80+ clinical recommendations, clinical algorithms, return-to-sport/activity, and return-to-learn/school concussion protocols as the evidence evolves. The best evidence from 2023 was collated and assessed, and new critical papers were shared in a living evidence map (EPPIreviewer). A quorum of 88% or more of the 48 experts voted on each update and consensus at 97-100% agreement was attained for all updates that were implemented. Significant updates to guideline recommendations involve revisions to the steps of the return-to-sport and activity protocol, highlighting the benefits of aerobic exercise in concussion treatment. Activities that pose no risk of sustaining a second concussion should be gradually resumed after 1-2 days even if mild symptoms are present. These symptoms may worsen mildly during activity as tolerated. Definitions of relative rest, mild to moderate intensity aerobic exercise, and mild symptom exacerbation have been harmonized with the Amsterdam International Consensus Statement on Concussion in Sport. Additionally, updates have been made to the timing of medical clearance and the definitions associated with it. The new return-to-school protocol reinforces the importance of promptly resuming school activities that do not have a risk of falling or being hit on the head, as tolerated, with the provision for academic accommodations if needed. It also emphasizes that the return to non-contact and low-risk school activities should not be restricted if the individual is effectively tolerating cognitive activities. The importance of restricting screen time in the early stage of recovery is now supported by strengthened evidence. Any activity with a risk of head impact or falling must still be entirely avoided until reassessment and medical clearance are obtained. All patients with a diagnosed concussion are recommended to return for a repeat medical assessment 7-10 days after the initial diagnosis and patients should be referred to specialized care with an interdisciplinary concussion team if post-concussion symptoms do not resolve by 2-4 weeks. Youth at increased risk of prolonged recovery require immediate referral. For more detailed information, including consensus voting details and complete recommendations, the pedsconcussion.com website serves as a valuable resource. Dissemination and implementation of these updates is essential to continue to improve outcomes for all pediatric patients with concussion. The collective efforts of the Living Guideline team highlight a commitment to continually advancing and improving pediatric post-concussion care practices.
159 Are We Putting the Best Interests of Patients First When Planning and Delivering Community-Based Care After Brain Injury?
Judith Gargaro1; Matthew Galati2; Nora Cullen3
1UHN-Kite Research Institute, Toronto, Canada; 2Scarborough Family Health Team, Toronto, Canada; 3Hamilton Health Sciences, Hamilton, Canada
Introduction
Traumatic Brain Injury is the leading global cause of disability. In Canada alone, 2% of the population lives with a TBI and many survivors require significant ongoing support and rehabilitation post injury in order to return to functional independence and achieve meaningful goals. In recent years, holistic treatment for TBI has become an increasingly popular approach to provide the brain with the best possible environment to heal. Some key lifestyle modalities, which may support a recovering brain, include nutrition, exercise, mindfulness, cognitive activity, good sleep and limiting harmful exposure. Although some of these interventions have evidence for supporting rehabilitation post TBI, the effects of combining these modalities into a larger program have not yet been studied. Furthermore, vital allied health care services needed to provide well-rounded care are costly for most individuals and persons who are members of traditionally marginalized groups are overrepresented in the population who do not have access to this type of care. Consequently, many patients are left untreated and lost to follow-up after their acute injury has been addressed and stabilized. This in turn leads to a tremendous burden on our healthcare system, as we know earlier and intensive treatment post TBI is important to mitigate long term disability.
Objective
To pilot a novel primary care clinical model designed to address gaps in TBI care and provide effective, equitable access to care,
Methods
The novel primary care model was developed through review of published evidence for key lifestyle modalities, which are the cornerstones of holistic care: nutrition, exercise, mindfulness, cognitive activity, good sleep and limiting harmful exposure. The model was refined through consultation persons with lived experience and clinicians to ensure feasibility and relevance to address current gaps in care. The model was piloted utilizing government funded regulated health professionals using a Family Health Team framework to promote continuity of care following discharge from acute care facilities.
Results
A structured model of care was developed that included quality indicators to assess process, outcome, and acceptability of care. This care model is consistent with the Ideal Care Pathways that is currently being implemented In Ontario. All patients referred to the care team were included in the pilot, regardless of severity of injury and personal circ*mstances. All had access to community based rehabilitative care with medical oversight that otherwise would not have been available to them. Patients reported high satisfaction with the model of care and the progress towards their identified goals.
Conclusion
This pilot represents an example of how holistic Family Health Team care can be effectively and efficiently provided in the community to support patients’ goals of living meaningful lives after brain injury.
160 Chronic Brain Injury: A Holistic Intake Assessment Tool for Clinical Practice
Thomas Watanabe1; Alan Weintraub2; Jacob Koffer3; Morgan Pyne4; Flora Hammond5
1Drucker Brain Injury Center MossRehab, Elkins Park, United States; 2University of Colorado School of Medicine, Aurora, United States; 3MossRehab, Elkins Park, United States; 4James A Haley Veterans Hospital, Tampa, United States; 5Indiana University School of Medicine, Indianapolis, United States
Chronic brain injury is associated with specific neurological, medical and psychological conditions that may decrease an individual’s functional capacities, their ability to live successfully, return to school or vocational endeavors, affect their relationships with others, and alter an individual’s quality of life. Over the last decade, numerous clinicians and researchers have emphasized the importance toward implementing a Chronic Care Model to manage the long term and often lifelong sequelae of Brain Injury.1 A model for service delivery was originally introduced by Masel and DeWitt 2 who stressed the importance of systematic Brain Injury care that extends beyond the acute and inpatient rehabilitation phase of management. This would include proactive expectant management of the lifelong needs for patients, families, and caregivers. timely and appropriate rehabilitation services, and addressing concomitant psychosocial issues such that individuals can maximize their capacities for community integration and societal participation. A formal and agreed upon standard of practice to evaluate and/or manage the complex needs of brain injury individuals and how those needs may dynamically change over time does not exist.
Aims: As part of the BeHEALTHY3 initiative, this feasibility project aligns with the goals of advancing a chronic disease management model for individuals with brain injury, their caregivers and health care providers. Following a systematic literature review, a BeHEALTHY working task force developed an easy to administer holistic and comprehensive intake tool for clinicians to utilize regardless of their specialty when managing the sequelae of chronic brain injury. Key concepts incorporated into the tool include:
1. A shared responsibility among the patient/family/caregivers and health care professionals emphasizing self-advocacy.
2. Promoting proactive and goal-oriented management plans aimed at meeting the dynamic and individualized needs of patients, families, and caregivers.
3. Emphasize collecting relevant preinjury and post injury medical and psychosocial history including mental health.
4. Emphasize the importance of evaluating an individual’s sensory-motor, neurocognitive, behavioral, social, community integration and societal participation status.
Components of the intake tool entails a Pre-visit assessment obtaining salient demographic information, relevant injury history, past medical and surgical history, medications, allergies, past hospitalization’s, current health care providers, family, educational and social history and a functional review of systems. This pre-visit tool will prepare the clinical providers for an in-person, holistic, targeted and time efficient initial intake that can be followed by personalized components of a general medical exam, neurological exam and “problem-specific and/or targeted functional exam.” Utilizing qualitative research methods for tool validation, reproducibility, comprehensiveness and ease of use, this can equip clinicians with a systematic tool useful in developing both a short- and long-term integrated management plan that can serve as a foundation for lifelong management.
161 Pharmacologic Use of PRN Medications for Agitation: “Examining the Weekend Effect”
Erin Miller1; Mitch Sevigny2; Stephanie Agtarap3; Alan Weintraub4; Robin Wackernah5
1HCA Florida Memorial Hospital, Jacksonville, United States; 2Craig Hospital, Englewood, United States; 3Craig Hospital, Englewood, United States; 4University of Colorado School of Medicine, Englewood, United States; 5Craig Hospital, Englewood, United States
Objective
To determine if PRN antipsychotic or benzodiazepine medication administration is increased over the weekends as compared to weekdays.
Design
Retrospective chart review
Setting
Acute inpatient neurorehabilitation hospital
Subjects
Patients admitted for moderate-severe traumatic brain injury and prescribed antipsychotics or benzodiazepines for agitation and/or aggression on an as-needed basis between 1900 Friday evenings and 0700 Monday mornings.
Main Measures
Primary outcome was the comparison of average daily number of administrations and daily medication dose between weekly and weekend PRN antipsychotic or benzodiazepine administration for agitation or aggression.
Results
Fifty-Seven patients with a total of 4,485 PRN administrations were included in the chart review. On the weekdays, benzodiazepine had an average prn dose of 4.3 mg and antipsychotics had an average prn dose of 78.7 mg. The weekend days showed an average prn dose of 3.5 mg and 82.6 mg for benzodiazepine and antipsychotics respectively. Statistically significant differences were found with benzodiazepines where there were larger doses administered on the weekdays when compared to the weekend days on average. No statistical differences were found with the antipsychotic doses.
Conclusion
There was no significant difference found between weekday and weekend administration with prn medications indicated for aggression/agitation to support higher antipsychotic or benzodiazepine use on the weekends. Further research to explore the consequences of and the key components of a deleterious negative “weekend effect” whereby no formal rehabilitative therapies occur on the weekends is warranted for programs treating persons with traumatic brain injury.
162 DTI Imaging of Decreased Fractional Anisotropy Demonstrating a Correlation With the Dysregulation of Emotions
Nickalus Yasunaga1; Mohammed Ahmed1
1Kaizen Brain Center, La Jolla, United States
Background
TBI leads to emotional dysregulation which is the inability to control one’s emotions (Weis et al., 2022). Diffuse Axonal Injury (DAI) is a hallmark of TBI which can be screened using Diffusion Tensor Imaging (DTI) sequencing in MRI. The exact neural correlate is unclear. Some earlier studies suggested axonal injury in the anterior limb of the internal capsule involving the white matter tracts. (Floeter et al., 2014)
Objective
Does DAI in the genu of the corpus callosum based on MRI with DTI sequence lead to emotional dysregulation in patients with TBI?
This paper aims to support the claim that there is a pathological problem associated with emotional dysregulation rather than it being due to an underlying mood or personality disorder (Parvizi et al., 2009).
Methods
We analyzed clinical records of patients between 2017-2023 at Kaizen Brain Center who were diagnosed with TBI related emotional dysregulation by a TBI specialist. We found 18 patients who had abnormal DTI on their MRI and then probed their clinical notes for emotional dysregulation based on the physician’s impression.
Results
Of the 92 TBI patients, 18 were found to have DAI in corpus callosum and diagnosed with emotional dysregulation. However, we did find that abnormalities in the genu were not exclusive to this correlation. Decreased FA in the splenium and other areas of the body also correlated with emotional dysregulation.
Conclusion
Abnormal DTI results due to DAI in corpus callosum may be a neural correlate of emotional dysregulation found in TBI Affective Disorder.
163 High School Football Players’ Knowledge and Attitude Regarding Concussions Contribute to a Staggering Occurrence of Unreported and Unrecognized Brain Injury
Grayson Elliott1,2; Diego Martell2,3; Edie Zusman2,4
1Watauga High School,Boone, United States; 2Safe Living Space, Oakland, United States; 3Yale University, New Haven, United States; 4Neuroscience Partners, Oakland, United States
Background
Concussions are a prevalent medical condition well recognized within professional and collegiate American football athletes, but less is known about the implications of concussions within adolescent populations. Recent studies indicate that approximately 67,000 high school football athletes are diagnosed with a concussion every year. Even with the high numbers of concussions diagnosed, high school football players may not adequately recognize or report the signs and symptoms of a concussion. Unrecognized and unreported brain injury should be of concern to health care providers given that adolescents experience longer and more diffuse cerebral swelling following neurological trauma compared to an adult population. Understanding the occurrence of concussions in high school American football athletes enables health care providers and coaches to properly assess adolescent athletes, while cultivating safer playing environments.
Objectives
The primary objective is to determine the occurrence of undiagnosed head trauma resulting from participation in high school football. The secondary objective is to understand why high school football athletes fail to recognize and report experiencing concussion-like symptoms.
Methods
A five question anonymous online survey tool was shared with a cohort of high school varsity football players at a single institution. The survey includes questions regarding the participant’s concussion history, presence of unreported concussion symptoms, and questions allowing respondents to further elaborate on their attitude and knowledge of concussion symptoms.
Results
Of 38 surveys shared, 81.6% (31 responses) were returned. While 90.1% of survey respondents reported having experienced concussion-like symptoms following a hit to the head during a game or practice within the most recent season, only 18.2% responded that they immediately left the field of play or sought medical attention. 12.9% of survey respondents were evaluated and diagnosed with concussion within the most recent football season. While 57% of survey respondents felt unable to determine if they may have had concussion symptoms, 35% of respondents who felt comfortable identifying their own concussions symptoms did not report them to a coach or trainer. The primary reason provided for not reporting recognized concussions symptoms was “fear of not immediately returning to the field of play.” Twenty-eight percent of study respondents reported that they experience prolonged concussion symptoms, lasting several weeks or even months.
Conclusion
While the majority of high school football players surveyed reported experiencing concussion-like symptoms, for many players the symptoms were not recognized and if recognized were not reported resulting in few players receiving standard medical treatment such as placement into a stepwise concussion protocol. Understanding why knowledge and attitudes about a concussion affects an individual’s willingness to seek medical attention immediately following head trauma is crucial to developing new narratives of concussion diagnostics, establishing general concussion awareness, and preventing long term health consequences.
164 Temporal Assessment of Hippocampal Susceptibility to Traumatic Brain Injury
Diana Gonzalez-Duque1; Efrain Buriticá1; Martha Escobar1; Gabriel Arteaga1; Melany Ayala1; DVictor Moreno1
1Universidad Del Valle, Cali, Colombia
Traumatic Brain Injury (TBI) constitutes a public health problem around the world that annually claims thousands of lives and is associated with extensive disability and great economic impact; it is defined as the sudden alteration of the brain tissue or its physiological functions as a result of the influence of external forces that exceed the resistance of the tissue. The objectives of this work were to temporally characterize the tissue, behavioral and molecular changes of the hippocampus after moderate TBI in Wistar rats as well as to determine if early management with minocycline can reverse and/or improve the consequences of the injury. It was found that diffuse TBI is associated with neuronal loss in the hippocampus, alterations in the axons and myelin sheaths, as well as reactive gliosis in all subregions, with increased activity of the matrix protease MMP9. Early intervention with minocycline achieved a positive effect on the reduction of neuronal dead, axonal degeneration, and neurofilament compaction with a very slight effect on MMP9 activity. This work is expected to contribute to the knowledge of the phenomena associated with the temporal pathophysiology of diffuse TBI in the hippocampus and further open up the possibilities of pharmacological intervention.
167 The BEST Approach for Cognitive Retraining After Medical Neurorehabilitation: An Educational Model for Building Skills, Independence, and Community
Michelle Wild1
1Brain Education Strategies & Technology, Laguna Hills, United States
Brain Education Strategies and Technology, Inc. (BEST) is a nonprofit organization started by Michelle Ranae Wild to share the theories she has developed over more than 30 years as a professor in Coastline Community College’s Acquired Brain Injury program to help people with acquired brain injury (ABI) retrain their brains, learn compensatory skills, and rebuild their lives. Through its unique, educational model, BEST provides people with ABI a curriculum and a community to help them continue to make progress after completing medical neurorehabilitation. BEST recognizes that ABI recovery is life-long and thus meets people at any stage of their journey.
BEST offers free webinars, multi-week workshops, facilitated discussions, and asynchronous online courses that are designed to teach people with ABI, their family members, and clinicians (1) how ABI can create physical, cognitive, behavioral, and emotional challenges and (2) practical strategies they can personalize to help them navigate those challenges. In the process, BEST provides participants with a supportive community where they can feel less isolated and learn from the experiences of others.
BEST introduces cognitive and technology topics through interactive webinars that include instruction, polls, monitored live chats, and Q&A sessions. The webinars are followed by facilitated “after hours” discussions on Zoom. These peer collaboration sessions are much-loved by BEST regulars and newcomers alike, because they reduce isolation and allow participants to feel like members of a safe, supportive community where they can share how the concepts taught in the webinar relate to their lives.
BEST workshop series address webinar topics in a more comprehensive, hands-on manner. They include a multi-week curriculum delivered through interactive, weekly Zoom sessions that feature breakout groups, whole class discussions, Q&A sessions, live chats, and the integration of technology tools as appropriate. Each session begins with an iterative review, designed to reactivate and consolidate learning from prior sessions. As with webinars, participants receive presentation slides, supplemental worksheets, and session recordings so they can engage and re-engage with the content at their own pace.
Program topics include cognitive rehabilitation, neurofatigue, executive function, self-regulation, problem solving, learning styles, communication, self-efficacy, initiation, and many more. BEST also teaches people with ABI how to use technology to compensate for ABI deficits. The BEST Suite of apps helps people organize their lives and apply the strategies they learn in BEST programs.
Data from participant evaluations indicates that BEST’s programs are indeed meeting participants’ needs. More than half have attended 6 or more BEST programs. A staggering 96% rate information they learned in the webinar as “very useful,” with 97% saying they learned something they can use in daily life.
This session will share the BEST approach to cognitive/neurorehabilitation and the feedback from participants.
168 Could Abuse-Induced Brain Injury and Strangulation Be a Physiological Risk Factor for Developing Multiple Sclerosis?
Larkin Stephenson1,4; Rachel Plouse1,2; Edie E. Zusman1,3
1Safe Living Space, San Francisco, United States; 2Touro Medical School Nevada, Henderson, United States; 3Neuroscience Partners, Moraga, United States; 4Northeastern University, Boston, United States
Background
Traumatic Brain Injury (TBI) is a commonly identified condition in athletes, veterans, and car accidents, however, TBI in the domestic violence and intimate partner violence (DV/IPV) population is critically underrecognized. Current literature estimates 74% of these violent events result in mechanical trauma to the head, neck, and face. Additionally, half of these injuries further result in an ischemic brain injury caused by strangulation. Repeated head trauma has been linked to an increased risk of developing multiple sclerosis (MS), predominantly in cohorts of women and children. Approximately 38%-63% of women with MS report prior experiences of abuse, and abuse may lead to earlier onset of illness and higher relapse rates. There are no identified interventional studies that address DV/IPV-induced TBI in the MS population.
Objective
The primary objective is to propose abuse-induced brain injury and strangulation as a physiologic risk factor for developing MS.
Methods
A PubMed search of articles September 2014 to November 2023 using key words multiple sclerosis in conjunction with traumatic brain injury, head injury, concussion, and/or strangulation as well as domestic violence and/or intimate partner violence retrieved ten papers. Articles were reviewed for proposed mechanisms and connections between TBI, MS, and DV/IPV.
Results
While no papers met all inclusion criteria, there is a significant epidemiological overlap between populations at risk of DV/IPV-induced TBI and those who develop MS. There is support in the literature for physiological mechanisms of increased intracranial pressure from venous outflow occlusion with strangulation, paired with the activation of astrocytes, degradation of tight junctions and a loss of blood-brain barrier (BBB) integrity seen with TBI. Disruptions of the BBB from central nervous system (CNS) injury proteins, including S100B, MBP, NSE, GFAP, UCHL-1, and NfL, enter the bloodstream and trigger an immune antibody response. Accumulation of TBI-induced proteins is linked to an increased risk of developing neurological diseases. Serum antibody IgG is released as a secondary immune response following IgM, which the injured CNS is unequipped to defend against following TBI-induced BBB degradation. Similar to ischemic brain injury, 24.8% of ischemic stroke patients have shown elevated oligoclonal IgG bands. Elevated levels of IgG have been established as a risk factor for MS. In TBI, the level of IgG has been associated with the severity and frequency of ischemia and TBI.
Conclusion
The literature suggests that TBI and venous outflow obstruction from strangulation may lead to inflammation thus activating the immune system and increasing the likelihood of developing the clinical syndrome of multiple sclerosis. This evidence-based theory highlights the probable link between abuse-induced brain injury and the risk of developing MS. Further research is necessary to establish this relationship and begin education, prevention, and care programs.
169 Lack of Accessible Health and Rehabilitation Services in Rural Counties Impacts Community Integration Following Traumatic Brain Injury
Elly O’Bryant1,2; Ren Mizuhara1; Daniel Ignacio1
1Saint Judes Brain Injury Network: HI-CARES, Fullerton, United States; 2California State University, Chico, Chico, United States
Incidences of traumatic brain injury (TBI) are responsible for over one million emergency department visits a year, and rehabilitation costs in the United States may well exceed $100,000, depending on the observed population and injury severity (Dismuke et al., 2015). A national inpatient survey found that the majority of TBI-related hospitalizations for urban (99.6%) and rural (80.3%) residents were located at an urban hospital (Daugherty et al., 2022). When comparing health care costs, individuals living in rural areas experience higher costs yet receive fewer services than urban residents (Graves et al., 2018). Additionally, individuals living in rural areas are at risk for poorer outcomes following TBI due to a lack of accessible resources (e.g., hospital care, neurosurgical interventions, and post discharge rehabilitative services) and must often utilize transportation services to travel to their providers (Brown et al., 2019). The disparities between rural and urban post-TBI care and rehabilitative services are a public health issue, and the overall stress due to lack of accessibility and decreased support can lead to further psychological, cognitive, and physical post-concussive symptoms. For the present study, data was collected from a representative and randomized sample of California residents in collaboration with California Department of Rehabilitation’s TBI Advisory Board and The California State Survey Panel, and from individual assessment packets from 2 out of 12 California Association for Traumatic Brain Injury (CATBI) sites in Northern and Southern California who provide services to improve the independent living and community reintegration for survivors of brain injury. The findings indicate that individuals living in rural counties engage in less community participation than those residing in urban counties. These differences can be explained by how accessible outpatient and rehabilitative services are in an individual’s residence. People with TBIs living in rural areas face many barriers as they reintegrate into their community, especially a lack of knowledge about programs and resources. The disparities between rural and urban post-TBI services and community integration can be diminished by increasing access to transportation and information about resources that are available.
171 Intersection of Traumatic Brain Injury and POTS (Postural Orthostatic Tachycardia Syndrome): Single Center Case Series
Sydney Myers1,2,3; Jaewon Choi1,4; Edie Zusman1,5
1Safe Living Space, San Francisco, US; 2University of California, Los Angeles, Los Angeles, USA; 3Lawrence Livermore National Laboratory, Livermore, USA; 4University of California, Berkeley, Berkeley, USA; 5Neuroscience Partners, Sacramento, USA
Introduction
While traumatic brain injury (TBI) is a recognized cause of postural orthostatic tachycardia syndrome (POTS), the prevalence of POTS among TBI patients is unknown, and the etiology of POTS following TBI is not well understood. POTS is characterized by orthostatic symptoms including dizziness, lightheadedness, fainting, and near syncope, but is also associated with cognitive dysfunction/attention deficits, sleep issues, headache, and anxiety. This collection of symptoms is attributed to dysfunction of the autonomic nervous system and can be seen in a subset of patients following TBI. Without a Tilt Table Test (TTT), POTS symptoms are often considered post-concussive and/or psychological leaving the underlying medical condition undiagnosed, with potential for increased concussion recovery time and decreased quality of life for TBI patients.
Objective
The goal of this retrospective case review is to determine the prevalence of POTS in a series of refractory post-concussion symptom patients, 6 months or more post injury, who were evaluated at a single interdisciplinary TBI and Concussion Clinic.
Methods
A retrospective chart review of 55 consecutive TBI patients evaluated between October 2022 and November 2023 was conducted. The patient’s gender, mechanism of injury, and symptoms associated with POTS were assessed.
Results
Sixty-five percent (36) had orthostatic issues characteristic of POTS including dizziness, lightheadedness, orthostasis, or near syncope. Additional symptoms often associated with POTS were also observed. Eighty nine percent (49) of patients had cognitive dysfunction/attention selectivity issues, 73% (40) had headaches, 67% (37) had anxiety, 56% (31) had sleep issues, 45% (25) had balance issues. Sixty-one percent of the patients with orthostatic symptoms were female.
Conclusion
Symptoms associated with POTS were seen in the majority of patients with refractory post concussive symptoms. These findings suggest that patients with refractory post concussive symptoms should be routinely evaluated for POTS. Conversely, given the correlation between TBI and POTS, patients with POTS should be assessed for signs and symptoms of TBI as many in this demographic may have unrecognized brain injury including sports injuries and abuse induced brain injury/strangulation. Further research is warranted on the intersection of TBI and POTS.
172 Optimal Positioning of Mandibular Occlusion: A Possible Important Factor to Reduce Head Concussive Injuries.
Denise Gobert1; Gregg Ueckert2; Mark Strickland3; Eric Linberg1; Leeda Rasoulian1; Bevyn Bryson1; Andrew Long1; Olivia Siciliano1; Ashley Aurit1; Clint Kennedy1; Dilyn Lyle1; Conlin Penland1; Meredith Moreland1
1Texas State University, Round Rock, United States; 2Ueckert Dentistry, Austin, USA; 3Strickland Physical Therapy Associates, Austin, United States
Background
Risk management of concussive blows to the head continues to be a challenge during several occupational and sports activities. Recent evidence suggests that there may be a significant negative relationship between neck strength/endurance and risk levels for concussion. (Collins 2014, Chavarro-Nieto 2021)
Purpose
To evaluate immediate differences in neck strength and endurance with and without customized, optimal mandibular interocclusal appliance positioning.
Design
Cohort Study Design with repeated testing.
Location
University Outpatient Physical Therapy Clinic
Methods
12 healthy participants (6 females/6 males) ages >18 yrs. were sampled by convenience. Inclusion criteria: normal cervical spine AROM, no recent head or neck trauma or surgery. Exclusion criteria: active cervical pain and any cervical spine postural abnormalities. Participants were fitted with a customized, mouth guard to properly align occlusal “bite” by a dentist while an orthopedic specialist, physical therapist assessed neck extension/flexion/rotation strength using the MicroFit® pressure gauge (Newtons) and grip strength using the Jamar hand dynamometer (kg/ psi). Last of all, timed isometric, cervical muscle contraction for neck flex/extension endurance was measured in seconds. Participants were tested in each activity without and then with the interocclusal appliance in place. Quality of life outcomes including the Neck Disability Index (NDI) and Disability Assessment of Shoulder & Hand (DASH) were used as psychosocial factors or covariates in all analyses.
Statistical Analysis
SPSS (vs.26.0, IBM Inc.) was used for descriptive statistics, paired T-Tests and 2-way repeated measures ANOVA to explore differences at p = 0.05 with a Greenhouse-Geisser correction factor. Multivariate mixed effects models were constructed to assess separate and combined influences of gender and condition on strength and endurance outcomes.
Results
There were significant differences found in strength based on Condition (F (1) 8.834, p =.018) and Position (F (1,8) = 134.226, p < 0.001). Significant differences were also observed in grip strength without vs with the MG (t (8) = -6.378, p < 0.001). There were also significant differences in endurance in both directions: Neck Flex Endurance Test-Supine, (t (8)= -2.334, p= 0.048), Neck Ext Endurance Test-Prone, (t (8)= -4.078, p = 0.002).
Conclusions
Preliminary results indicate a significantly increased neck strength and endurance with a jaw interocclusal appliance for optimized positioning compared to no appliance use.
Clinical Relevance
Suggested gains in cervical spine strength and endurance may assist concussion risk management for contact sports at all levels. Preliminary results also suggest the need for further research about how proper jaw alignment might optimize neck muscle strength over a broad spectrum of subjects regardless of sex, ages or athletic ability.
173 Prevalence of Accommodative and Vergence Dysfunction in Collegiate Varsity Athletes With and Without History of Concussion
Jacqueline Theis1; Casey Batten4; Michael Silver2
1Virginia Neuro-optometry, Richmond, United States; 2University of California at Berkeley, Berkeley, United States; 3Uniformed Services University, Bethesda, United states; 4Cedars Sinai - Kerlan Jobe, Los Angeles, United States
Oculomotor dysfunctions, including convergence and accommodative disorders, are common in up to 80% of patients with acute concussion and 30-40% with chronic concussion. However, convergence and accommodative disorders are not specific to concussion, and they can also be present from development/non-traumatic origin. While there is a high (20-30%) prevalence of oculomotor dysfunctions in the non-concussed clinical pediatric population, prevalence of oculomotor dysfunctions in collegiate athletes is currently unknown, and this imposes strong limits on conclusions that can be drawn from studies of visual and vestibular-oculomotor dysfunction following suspected concussion. This study collected baseline oculomotor data to assess the presence of vergence and accommodative dysfunctions in collegiate varsity athletes with and without a history of concussion.
Methods
All experimental procedures were IRB approved. Intercollegiate varsity athletes at the University of California, Berkeley were asked to participate in a comprehensive oculomotor assessment. Athletes were asked about their concussion history and were cleared from prior concussions by the team physician prior to baseline testing. All baseline oculomotor examinations were conducted by the same optometrist.
Results
Baseline data were collected on a total of 179 athletes. Athletes were assigned to groups either with (n=63, 17 females, 45 males) or without (n=116, 32 females, 85 males; control group) a history of a diagnosed concussion. Refractive correction of either glasses or contact lenses were worn by 22.9% (n=41) of the sample. Participants reported whether they had received at least one eye examination with an eyecare provider in their lifetime (52.5%; n=94) and whether they had received an eye examination within the last year (35.75%; n=64).
Baseline binary variables (proportions) were compared using Fisher’s exact test, and continuous variables were compared using the non-parametric Wilcoxon rank sum test. There were no statistically significant differences between groups for any of the oculometric measures. Notably, when compared to clinical norms, there were multiple clinically relevant oculomotor dysfunctions at baseline, including abnormal near cover test (11.2%), reduced fusional divergence at near (15.1%), reduced fusional convergence at near (29.1%), reduced near point of convergence (6.2%), reduced near point of accommodation (13.4%), and reduced accommodative facility (20.1%).
Conclusion
There were no statistically significant differences between athletes with or without a history of concussion for convergence or accommodative (dys)functions. Athletes exhibited clinically relevant levels of accommodative and vergence dysfunction at baseline, and 47.5% of the sample had never had a comprehensive eye exam in their lifetime. This lack of information regarding baseline oculomotor function in athletes confounds possible baseline abnormalities with those resulting from suspected concussions. This, in turn, can impact their education, sports performance and pull-from-play and return-to-play decisions.
174 Differentiation of Cervical, Oculomotor, and/or Vestibular Dysfunction: Using Clinical Testing to Optimize Evaluations and Rehabilitation Triage Post-Concussion COVA Study Group
Jacqueline Theis1,2,3; Sara Etheredge3; Edie Zusman4; Cristen Kaae5; Kristen Cadigan5; Vera Pertsovskaya
1Virginia Neuro-optometry, Richmond, United States; 2Uniformed Services University, School of Medicine, Bethesda, United States; 3Concussion Care Centre of Virginia, Richmond, United States; 4Neuroscience Partners, Moraga, United States; 5Kaiser Permanente Medical Center, Vallejo, United States
Introduction
Patients who suffer from traumatic head injury are at risk of developing traumatic brain injury, traumatic whiplash injury, or both. The majority of these patients present to multiple disciplines of providers including pediatricians, internal medicine, sports medicine, and emergency medicine with nonspecific complaints including headache, dizziness, nausea, brain fog, and anxiety. The majority of these patients self-resolve within 4-6 weeks however approximately 10% will have persistent symptoms for months, years, or indefinitely. Tools like the VOMS (Vestibular Oculomotor Screening Assessment) have been instrumental in screening for visual-vestibular disorders to allow for referral to vestibular physical therapy. However, not all patients fully resolve with standard vestibular physical therapy and may worsen if the etiology is cervical or oculomotor.
Methods
We present a case series of 15 patients who presented to a transdisciplinary brain injury clinic to be evaluated by neuro-optometry and orthopedic physical therapy after failing vestibular physical therapy post-concussion. The cases have been reviewed with a distinguished national cohort of concussion experts including neuro-optometry, neurosurgery, orthopedic and vestibular physical therapy to propose a novel clinical assessment. Cervical-Oculomotor-Vestibular Assessment (COVA) that could help all providers differentiate cervical, vestibular, and oculomotor dysfunctions to provide more appropriate referrals to rehabilitation specialists and specialty providers.
Results
The subset of patients with refractory or worsening post concussive symptoms following vestibular physical therapy benefit from a clinical assessment based on simple, subjective and objective testing which can be done chairside or bedside based on the nuances of neuro-anatomy and pathophysiology of whiplash vs traumatic brain injury vs traumatic brainstem injury.
Conclusion
The cervical, oculomotor, and vestibular systems are intimately connected neuro-anatomically and are often underlying causes of common post-traumatic symptoms like headaches, nausea, dizziness, and brain fog. By varying the methodology of oculomotor testing from current clinical screening assessments, clinicians may be better able to identify the underlying trigger for symptoms, and triage to the appropriate provider and rehabilitation type.
175 Primary Care Provider Follow-up and 90-Day Outcomes Following Community Discharge Among Older Medicare Beneficiaries With Traumatic Brain Injury (TBI) in Texas
Monique Pappadis1,2; Ioannis Malagaris1; Yong-Fang Kuo1; Natalie Leland3; Janet Freburger3; James Goodwin1
1University of Texas Medical Branch, Galveston, United States; 2Brain Injury Research Center at TIRR Memorial Hermann Hospital, Houston, United States; 3University of Pittsburgh, Pittsburgh, United States
Primary care providers (PCP) are essential during the transition from hospital to community, but little is known about whether having a primary care visit will improve post-hospital outcomes among older adults with TBI. Therefore, we examined the predictors of PCP follow-up with an established PCP or any PCP, and its association with 90-day emergency department (ED) use and all-cause hospital readmission, using Cox regression models based on competing risks (death and hospice admission) and censoring (until loss of Medicare coverage, by 90th follow-up day, or by December 31, 2019). The interaction effect of visiting any PCP or established PCP with discharge destination (i.e., home, home health, skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), nursing home, other facility) was also examined. Using 100% Texas Medicare data, we identified 27,480 older patients aged 66 and older hospitalized for TBI from January 1, 2014 and discharged by September 30, 2019, and returned home within 90 days following hospital discharge. Prior to the TBI, about 70% of older patients had an established PCP. By 90 days following discharge home, 79.5% of patients with an established PCP saw their provider, whereas 37% of patients without an established PCP saw any PCP. Patients who were more likely to see any PCP within 90 days after discharge home were female, of Hispanic ethnicity, discharged home from an IRF, or had an established PCP. Patients aged 70-84, of Black race, Medicare/Medicaid dual eligible, with primary TBI diagnosis, and discharged from an IRF were more likely to see their established PCP within 90 days from discharge home. Patients who saw any PCP and were discharged home were less likely to have an ED visit (HR=0.81; CI: 0.76-0.87) and hospital readmission (HR=0.87; CI: 0.81-0.95). Increased likelihood of ED service utilization was found among patients who visited any PCP and were discharged from either a SNF (HR=1.12; CI: 1.02-1.22) or IRF (HR=1.17; CI: 1.06-1.28). Those who visited any PCP and discharged home from an IRF were also more likely to be readmitted (HR=1.16; CI: 1.04-1.30). Patients with a previously established PCP who saw the same PCP and were discharged home following hospitalization were less likely to have an ED visit (HR=0.82; CI: 0.75-0.89) and be readmitted (HR=0.84; CI: 0.77-0.92). Older patients who visited their established PCP and were discharged from an IRF were more likely to have an ED visit (HR=1.16; CI: 1.04-1.29) and be readmitted (HR=1.14; CI: 1.00-1.29, p=0.046). In summary, for older patients with TBI who did not receive post-acute care, having a PCP was associated with better post-hospital outcomes, while those who received post-acute care may need care transition support. The role of continuity of primary care plays in TBI outcomes needs to be further explored.
176 The Impact of REM Sleep in Memory After a Traumatic Brain Injury and the Importance of Considering Sex a Biological Variable
Stefanie Howell, Grace Griesbach
1Centre for Neuro Skills, Tarzana, United States; 2David Geffen School of Medicine, UCLA, Los Angeles, United States
Sleep-wake disturbances (SWD) are common following TBI, and often extend into the chronic phase of recovery. Such disturbances in sleep can lead to deficits in executive functioning, attention, and memory consolidation, which may ultimately impact the recovery process. We examined if SWDs following TBI were associated with morbidity during the post-acute period. Particular attention was placed on the impact of sleep architecture on learning and memory. Because women are more likely to report SWDs, we examined sex as a biological variable. We also examined subjective quality of life, depression, and disability levels. Data was retrospectively analyzed for fifty-seven TBI patients that underwent an overnight polysomnography. Medical records were reviewed to determine cognitive and functional status during the period of the sleep evaluation. Consideration was given to medications, as a high number of these are likely to have secondary influences on sleep characteristics. Women showed significantly higher levels of disability and reported more depression and lower quality of life. A sex dependent disruption in sleep architecture was observed, with women having lower percent time in REM sleep. An association between percent of time in REM and better episodic memory scores was found. Melatonin utilization had a positive impact on REM duration. Improvements in understanding the impact of sleep-wake disturbances on post-TBI outcome will aid in defining targeted interventions for this population. Findings from this study support the hypothesis that decreases in REM sleep may contribute to chronic disability and underlie the importance of considering sex differences when addressing sleep.
177 Coma Recovery Scale–Revised is Better to Be Performed in an Upright Position Rather Than a Lying Position in Patients With Disorders of Consciousness
Bei Zhang, Andrew DaCosta2,3; Aya Bou Fakhreddine4; Stephanie Stroever4; Katherine O’Brien2,3,5
1Division of Physical Medicine and Rehabilitation, Department of Neurology, Texas Tech University Health Sciences Center, Lubbock, USA; 2TIRR Disorders of Consciousness Program, TIRR Memorial Hermann, Houston, United States; 3Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, United States; 4Division of Biostatistics, Clinical Research Institute, Texas Tech University Health Science Center at Houston, Lubbock, United States; 5H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, United States
It is unclear whether the assessment position of patients with Disorders of Consciousness (DoC) affects the result of Coma Recovery Scale–Revised (CRS–R). Currently, only the arousal protocol is required to facilitate patients’ engagement and accurate scoring. The study aims to investigate the impact of positioning on the CRS-R total score. This is a retrospective study analyzing a total of 1470 CRS-Rs performed on 232 patients in four different positions, i.e., lying in bed (Bed), sitting at the edge of a mat (Mat), sitting in a wheelchair (Wheelchair), and up in a standing position (Standing), in an acute inpatient rehabilitation setting. A conditional random coefficients multi-level model was used to examine the changes of CRS–R based on the position, accounting for repeated measurements within subjects and the variability introduced by different raters. The cohort contains 65.1% male, age 37.4±16.2, and includes primarily traumatic brain injury (47.0%) and hypoxic-ischemic brain injury (26.7%). Each patient underwent an average of 10.3±6.8 CRS–Rs. The mean CRS–R total score was 7.4±4.1. The average arousal protocol used was 3.0±2.1 per session. We found that the CRS–R total score was significantly associated with the assessment position. Using the Bed as reference (controlling age, gender, etiology, number of arousal protocol used, and days post-injury), patients assessed in the Mat, Wheelchair, and Standing had estimated 1.3-, 1.1-, and 1.5-point increases in the CRS–R total score, respectively (P = 0.002, 0.008, and 0.050; overall, upright vs. lying, 1.2-point increase, P = 0.003). The CRS–R total score was found significantly associated with the number of arousal protocols used. However, it was estimated that with every additional administration of the arousal protocol, the CRS–R total score decreased by 0.8-point (P < 0.001). We further identified that, using the Bed as reference, the number of arousal protocol used was not associated with the assessment position, with and without controlling the abovementioned factors. Our results demonstrated that the increased use of arousal protocols indicated lower arousal level at baseline, thus, poorer CRS–R performance. The increased use of arousal protocols did not serve to improve CRS–R performance. The assessment position appears to be more important. Patients scored significantly higher in an upright position. One point change could potentially make a diagnostic difference in the CRS–R. The finding may be related to generally improved physical and cognitive functionality in an upright body position, rather than to arousal only. The arousal protocol needs to be applied as indicated regardless of the assessment position. In conclusion, CRS–R is better to be performed in an upright position rather than a lying position in patients with DoC.
178 Value of Group Holidays for Clients With Catastrophic Injury
Maggie Sargent
I arrange ski trips for adults and children, safaris in Africa, surfing in the UK, and camping in Europe. We have captured in pictures on our poster our clients in different environments and facing new challenges, and we have feedback from our clients confirming the benefit they and their families obtain from these experiences. The group holidays increase their confidence and self-esteem, and clients have discussed with me that they gained an insight into their own conditions from the experience and how ‘It was the first time I felt normal’ and, ‘I realized that I could function in a group and enjoy myself’ and are part of the story of how they progressed.
We saw physiotherapy benefits from surfing in the UK and in Africa. We took a brain-damaged, ventilated client skiing in France, showing there are no physical boundaries. We facilitate children’s trips that show us the value of activities with siblings e.g. a child going down an advanced run in contrast to the rest of the family, who are on basic runs! These trips demonstrate that such activities benefit both family and carers.
It is not necessary to go overseas for some clients: similar benefits can be obtained from a surfing holiday in Devon, UK. The safari was a very positive experience, ranging from snorkeling and shark cage diving, to surfing. We saw animals from an accessible open-top vehicle and hippos from a boat and took a group to a special-needs orphanage, and they raised money for the children and we then took the children to the beach for what was their first outing. It became difficult to tell who were clients, guides, support workers, or family.
